New Passport Wellness

Passport Date

Preventive clinical data

Height
Inches (in)Meters (m)

Weight

Peripheral temperature in hands

Peripheral temperature in feet

Hydration test
NormalAltered

Postural evaluation

Head
NormalAntepulsion

ATM
FunctionalDysfunctional

Cervical spine
NormalRectificationHyperlordosis

Right Shoulder
NormalAntepulsion
Internal rotation

External rotation

Left Shoulder
NormalAntepulsion
Internal rotation

External rotation

Thoracic spine
NormalAltered

Lumbar spine
NormalRectificationHyperlordosis

Pelvis
NormalAntepulsionRetropulsion

Right Hip
NormalBlocked
Internal rotation

External rotation

Left Hip
NormalBlocked
Internal rotation

External rotation

Knees
NormalAltered

Feet
NormalAltered

Balance test
NormalAltered

Hand grip

Surgical history

History of injuries

Family health history

Habits

Front Image

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Side Image

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Back Image

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