Straight Leg Raise Assessment Form
Record patient details and clinical findings for the straight leg raise assessment.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Side Tested
*
Left
Right
Both
Pain Presence During Test
*
Yes
No
Pain Severity (if present)
1
2
3
4
5
6
7
8
9
10
Degree of Leg Raise Achieved (in degrees)
*
Reproduction of Symptoms
*
Back pain
Leg pain
No symptoms
Other
Assessment Table
Rows
Degree Achieved
Pain (Y/N)
Left Leg
1
Right Leg
2
Additional Notes
Submit Assessment
Should be Empty: