1. General Information

Examinee
Name:	Jane Doe
Address:	N/A
City, State, ZIP:	N/A
Social Security Number:	N/A
Employer:	Johnson
Occupation:	Staffing Coordinator / Central Supply
Current Evaluation
Date of Evaluation:	12/19/2002 12:06:48
Evaluated by:	John Chimney
Site of Evaluation:	Site 1: Kinematic Consultants
Comments:	Report generated by APAS/Wizard 0.5
Referral Source:	John Doe, M.D.
Insurance Administrator:	Johnson Insurance
Case Number:	N/A/
Claim Number:	2138709123897

2. Case History

Initially evaluated
Physician:
Diagnosis:	Herniated Disk
Date of Incident:	12/19/2002 12:08:17
Complaints:	1. Constant Pain in cervical spine and lower back with radiating pain into B. LE's to toes 2. Frequent shicking pain from back to neck. Pain increasing with activity 3. Difficuly sleeping. Difficulty performing ADL's, cleaning, cooking 4. Currently pain 6/10
Height:	5'2"
Weight:	225
Date of injury:	12/5/2003 12:08:17
Type of incident:	M.V.A.
Required assistance:	True
Continued to work:
By:	John Chimney, M.D.
Test and Tx::	MRI, X-rays
Result:
Specialty Referral 1
By:
Test and Tx::
Result:
Specialty Referral 2
By:
Test and Tx::
Result:
Surgery 1
Date:	12/19/2003 12:08:17
By:
Type:
Surgery 2
Date:
By:
Type:
Surgery 3
Date:
By:
Type:
Return to work:
Status:
Comments:

3. Job Information

Job Description:
Provided by:
DOT Number:
Work Level Category - DOT:	Sedentary
Work Level Category - Employer:	Sedentary

4. Physical Evaluations

Normal values reflected herein are from the AMA Guides to the Evaluation of Permanent Impairment, 4th Edition

Posture:

5. Cervical Spine Analysis

A computer kinematic assessment is performed for cervical flexion/ extension, lateral flexion and rotation. The Examinee is asked to perform each maneuver 8-10 repetitions to full range and as quickly as possible. The events are videotaped in a precisely calibrated field for computer analysis. Each event is analyzed for total dynamic range of motion and peak velocity quantity and quality. Consistency of results [coefficient of variation] is considered for determining Examinee effort. After a thorough discussion of expectations, and agreement of understanding by the Examinee, the Examinee is asked to perform the movement events.

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Figure 1: Cervical Flexion

Figure 2: Cervical Extension

Chart 1: Cervical F/E Displacement

Table 1: Cervical F/E Displacement

Results in degrees	Average	%Deficit
Flexion	45	N/A
Extension	45	N/A
Coefficient of Variation

Chart 2: Cervical F/E Velocity

Table 2: Cervical F/E Velocity

Results in deg/sec	Examinee
Flexion/Extension	N/A
Coefficient of Variation	N/A

Figure 3: Left Cervical Lateral Flexion

Figure 4: Right Cervical Lateral Flexion

Chart 3: Cervical Lateral Flexion Displacement

Table 3: Cervical Lateral Flexion Displacement

Results in degrees	Average	%Deficit
Right Cervical Lateral Flexion	45	N/A
Left Cervical Lateral Flexion	45	N/A
Coefficient of Variation

Chart 4: Cervical Lateral Flexion Velocity

Table 4: Cervical Lateral Flexion Velocity

Results in deg/sec	N/A
Rotation	N/A
Coefficient of Variation	N/A

Figure 5: Left Cervical Rotation

Figure 6: Right Cervical Rotation

Chart 5: Cervical Rotation Displacement

Table 5: Cervical Rotation Dynamic Range of Motion

Results in degrees	Average	Examinee	%Deficit
Right Rotation	60	N/A	N/A
Left Rotation	60	N/A	N/A
Coefficient of Variation			N/A

Chart 6: Cervical Rotation Velocity

Table 6: Cervical Rotation Velocity

Results in deg/sec	N/A
Rotation	N/A
Coefficient of Variation	N/A

Summary Protocol 5: Kinematic Neck Summary

Kinematic neck assessment indicated Examinee demonstrates residual cervical dysfunction
Percent average residual dysfunction vs normals is currently	N/A
Coefficient of variation average	N/A
Examinee's effort during this FCE is considered maximum due to C.V. 10%

6. Shoulder Involvement Analysis

A computer kinematic assessment is performed for shoulder flexion/extension, abduction/adduction, and internal/external rotation. The Examinee is asked to perform each maneuver 8-10 repetitions to full range and as quickly as possible. The events are videotaped in a precisely calibrated field for computer analysis. Each event is analyzed for total dynamic range of motion and peak velocity quantity and quality. Consistency of results [coefficient of variation] is considered for determining Examinee effort. After a thorough discussion of expectations, and agreement of understanding by the Examinee, the Examinee is asked to perform the movement events.

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Chart 7: Shoulder F/E Displacement