Assessment Form
Name DOB
Observation and Posture
Hand Dominance ___ R ___ L
Posture: Front View
___ Normal
___ Head tilt
___ Shoulder height
___ Arm internal rotation
___ Pelvis height
___ Scoliosis
___ Foot external rotation
Posture: Side View
___ Normal
___ Forward head posture
___ Thoracic kyphosis
___ Lumbar lordosis
___ Flat back
___ Military
___ Sway back
Lumbar Curve Test
___ Normal ___ Lordotic ___ Flat
Additional comments:
E6504/Canfitpro WR/FIG01.01/525356/pulled/R1
Dynamic Postural Assessment pulled from:
E4585_338177 & 338179
Initial assessment Follow-up assessment
Date Score Date Score Movement errors noted
Seated spinal
rotation
Straight-leg raise
Overhead squat
(ROM)
Overhead squat
(endurance)
©
2016 canfitpro
Cardiorespiratory Fitness Assessment
Initial assessment Follow-up assessment
Submax
. Submax
.
Test Date HR VO2 Date HR VO2
Muscular Capacity Assessment
Follow-up
Initial assessment assessment
Test Date Score Date Score
Strength
Normative
Endurance
Strength
Non-normative
Flexibility Assessment
Initial assessment Follow-up assessment
Date Trial 1 Trial 2 Date Trial 1 Trial 2
Sit-and-reach
test
Right reach Left reach Right reach Left reach
Shoulder Date down down Date down down
flexibility test
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2016 canfitpro
Dynamic Postural Assessment Scoring Chart
Score Description
Seated spinal 0 Pain or greater than 35 cm from doorjamb (or 40 cm from pole)
rotation 1 More than 20 cm and less than 35 cm from doorjamb (or 25-40
cm from pole)
2 More than 5 cm and less than 20 cm from doorjamb (or 10-25
cm from pole)
3 Less than 5 cm from doorjamb (or less than 10 cm from pole)
Straight-leg raise 0 Pain or could not achieve core neutral
1 Minimal change in core neutral and minimal knee flexion (part
1); test leg aligns with tester’s ASIS farthest from head (part 2)
2 No change in core neutral and no knee flexion (part 1); test leg
aligns with tester’s navel (part 2)
3 Same as part 1; test leg aligns with tester’s ASIS closest to
head (part 2)
Overhead squat 0 Pain or fails to perform level 1 with full range of motion (femur
(ROM) below parallel)
1 Full range of motion for level 1 (heels elevated)
2 Full range of motion for level 2 (heels flat)
3 Full range of motion for level 3 (toes elevated)
Overhead squat 0 Unable to maintain thighs parallel to floor and arms in line with
(endurance) ears
1 Holds squat position for 0-30 seconds without losing balance or
stopping
2 Holds squat position for 31-60 seconds without losing balance
or stopping
3 Holds squat position for 61-90 seconds without losing balance
or stopping
©
2016 canfitpro
Dynamic Postural Assessment Movement Errors Chart
Description
Seated spinal Torso not upright
rotation Upper back rounded (flexed)
Dowel not parallel to floor (torso side bend/lateral flexion of spine)
Asymmetrical rotation (>25 cm difference from side to side)
Straight-leg raise Bent knees (unable to keep legs straight)
Foot is externally rotated during leg lift
Ribs and thorax shift vertically (not belly breathing)
Significant bulging in abdominal region
Unable to hold core neutral (back arches)
Plane changes in ASIS (pelvis rotates)
Overhead squat Forearms not equal distance from ears
Arms not straight (note which side has greatest bend)
Dowel aligned over or behind heels
Dowel rotated forward (closer to wall on one side compared to the other)
Loss of balance
Upper back rounded (flexed)
Lower back arched (anterior pelvic tilt)
Lower back flattens (posterior pelvic tilt)
Weight shifts towards one side (note which side)
Hip higher on one side (note which side)
Knee not tracking over second toe
Tibia and upper torso not parallel
Ankle pronates or supinates
Normative Muscular Endurance Scoring Chart
Score Description
Push-up test 0 Pain or able to complete no more than 10 repetitions
(from toes) 1 Client completes 11-22 repetitions
2 Client completes 23-40 repetitions
3 Client completes 41 or more repetitions
Push-up test 0 Pain or able to complete no more than 8 repetitions
(from knees) 1 Client completes 9-20 repetitions
2 Client completes 21-35 repetitions
3 Client completes 35 or more repetitions
Horizontal pull-up 0 Pain or able to complete no more than 5 repetitions
test (flat) 1 Client completes 6-10 repetitions
2 Client completes 11-19 repetitions
3 Client completes 20 or more repetitions
Horizontal pull-up 0 Pain or is able to complete no more than 2 repetitions
test (45°) 1 Client completes 3-6 repetitions
2 Client completes 7-12 repetitions
3 Client completes 13 or more repetitions
©
2016 canfitpro
Normative Muscular Endurance Movement Errors Chart
Description
Push-up test Shoulder(s) elevates during the push-up (note which side)
Torso does not lift as a unit (loses contact with dowel)
Knees do not remain fully extended (if done from the toes)
Client’s thighs or hips touch the floor
Horizontal pull-up Shoulder(s) elevate on initiation of pull (note which side)
test Torso and hips do not lift as a unit
Excessive arching of the lower back occurs
Knees do not remain fully extended
Abdominal Forearms not equal distance from ears
curl-up test Arms not straight (note which side has greatest bend)
Dowel aligned over or behind heels
Dowel rotated forward (closer to wall on one side compared to the other)
Loss of balance
Upper back rounded (flexed)
Lower back arched (anterior pelvic tilt)
Lower back flattens (posterior pelvic tilt)
Weight shifts toward one side (note which side)
Hip higher on one side (note which side)
Knee not tracking over second toe
Tibia and upper torso not parallel
Ankle pronates or supinates
©
2016 canfitpro
