Musculoskeletal Assessment

Surname First Name

Assessment Date Position
Assessor Company

Patient Questionnaire Yes No Comments

1. Do you do regular exercise or organised sport?

2. Have you ever had problems with your

back/neck?

3. Have you had any operations in the past?

4. Have you been involved in a motor vehicle

accident?

5. Have you ever broken any bones?

6. Have you ever had any head injuries

/concussions?

7. Do you have any recurring joint or muscle

problems?

8. Have you had any other injuries, dislocations,

sprains, tears, partial or full amputations?

Blood Pressure (To be completed prior to any examination)

2nd Reading if 3rd Reading if
1st Reading
>140/90mmHg >140/90mmHg
Pre-existing injuries

Right Left Ambidextrous Comments

Dominant hand   
Posture

Walking

F-MED-001 Reviewed: 14/04/2022 PGS

Musculoskeletal Assessment
Restriction = Restriction which could impact the ability to perform job role, increase injury risk and/or be
exacerbated by performing job/role
Minor Restriction = Restriction which will not impact the ability to perform job role, increase injury risk and/or
be exacerbated by performing job/role

Range of Motion
Minor
Restriction Normal Comments
Cervical: Restriction
Flexion   
Extension   
Right Rotation   
Left Rotation   
Right Lateral Flexion   
Left Lateral Flexion   
Thoracic:
Flexion   
Extension   
Right Rotation   
Left Rotation   
Right Lateral Flexion   
Left Lateral Flexion   
Lumbar:
Flexion   
Extension   
Right Quadrant   
Left Quadrant   
Straight Leg Raise (R)   
Straight Leg Raise (L)   
Shoulder:
Flexion   
Extension   
Abduction   
Empty Can Test   
Elbow:
Flexion   
Extension   
Pronation   
Supination   
Wrist & Hand:
Flexion   
Extension   
Wrist Circumduction   
Finger Dexterity   
Hip
Flexion   
Extension   
Internal Rotation   
External Rotation   
Knee:
Flexion   
Extension   
MCL/LCL   
ACL/PCL   
Ankle & Foot:
Dorsiflexion   
Plantarflexion   
Eversion   
Inversion   

Squats x 10
Restriction Minor Normal Comments

F-MED-001 Reviewed: 14/04/2022 PGS

Musculoskeletal Assessment
Restriction

  

Grip Strength
Right Left Comments
Pain with Grip Y/N
Strength in Kgs kgs kgs
Normal Y/N

Plank Test

Unable to 1 – 14
 sustain  Seconds  15-29
Seconds  30 – 44
Seconds  45 – 60
Seconds  > 60
Seconds

Comments

Manual Handling Strength and Function

 Unable  0-5kgs  6-10kgs  11-15kgs  16-20kgs  > 20kgs

Lifting Technique Restriction Minor Restriction Normal

Demonstrates a good base of support which is close to load   
Adequate knee bend when lifting and lowering load to support
  
weight
Maintains neutral spine position with load maintained close to
  
torso
Shoulders, torso, hips, legs and feet remain facing in the same
  
direction
Displays good technique releasing and walking away from
  
load

Overall Risk Impression and Recommendations

Minimal

Moderate

High

Recommendation(s)

Qualification Date

Signature Stamp

F-MED-001 Reviewed: 14/04/2022 PGS