Name *

First Name

Last Name

Date

MM

DD

YYYY

Pain Intensity Scale

0

1

2

3

4

5

6

7

8

9

10

Mobility

Forward Flexion

Strength

Bicycling Trunk Posture (1 min)

SL Squat Progression - 45 deg, 60 deg, 90 deg, SL Hop

SL Calf Raise

Mobility

Ischial Tuberosity Width

Cervical Extension (60 deg)

Wrist

Strength

Biceps

Wrist

Grip

Mobility

Hip Flexion (130 deg)

Hamstring Length - 75 deg, 90 deg

Patellar Mobility

LLD

Gluteal ER Length (80 deg)

Strength

Triceps/Pec Major

Hamstring

Mobility

Prone Knee Bend (heel to glut)

Thoracic Extension

Strength

Superman (1 min)

Push-Ups (20)

Lat. Dorsi

SLP

60 rpm, light resistance

Gear chosen - low, high (novice)

Fluidity of pedal stroke

Constant rotational velocity

4-6 reps/leg at 30-45 sec

Min acceleration/deceleration

Symmetry b/w legs

High Cadence

Light resistance

Pedal at 120 rpm x2 min

Minimal bouncing