Lower Extremity Physical Examination Checklist Form
Complete this checklist to document findings from the lower extremity physical exam.
Patient Full Name
*
First Name
Last Name
Inspection Findings (e.g., swelling, deformity, discoloration)
*
Palpation Findings (e.g., tenderness, warmth, masses)
*
Range of Motion Assessment
*
Please Select
Normal
Decreased
Increased
Painful
Muscle Strength (0-5 scale)
*
Please Select
0 (No movement)
1 (Trace movement)
2 (Movement with gravity eliminated)
3 (Movement against gravity)
4 (Movement against some resistance)
5 (Normal strength)
Sensation Assessment
*
Intact
Decreased
Absent
Other
Reflexes
*
Patellar normal
Patellar decreased
Achilles normal
Achilles decreased
Other
Vascular Assessment
*
Pulses normal
Pulses diminished
Edema present
Capillary refill delayed
Gait Analysis
*
Please Select
Normal
Antalgic
Trendelenburg
Other abnormal
Special Tests (e.g., Lachman, McMurray, Drawer sign)
Submit
Should be Empty: