8/16/2019 Cervical Eval Form
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Cervical Evaluation
Name______________________________
DX______________________________________________
Date:_____________
Current
Meds___________________________________________________________________________________________ PMH__________________________________________________________________________________________________
Physician_______________________________Next
Appt___________________Onset_______________
Initial Evaluatin:_____ !e"Evaluatin:_____ Pain !atin#_________
$unct% !atin#__________
SUBJECTIVE: !adiatin# pain ! & ___________________
Num'ness( )in#lin# ! & ______________________
)ru'le sleepin# _____* Hurs( ni#ht_____ +ymptms ,rse in A%M%
P%M% Headaches: - N $re.uency:_________
_______________________________________________________________________________________________________ _______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
C(c:____________________________________________________________________________________________________ Occupatin(+cial
Hx:_____________________________________________________________________________________
/r0
Duties:____________________________________________________________________________________________
Pt%
1als:_______________________________________________________________________________________________
OBJECTIVE:
Observation: _____ /N&
_____!unded shulders_____$r,ard head mid")hracic 2yphsis
↑ ↓
upper )hracic 2yphsis ↑ ↓ &um'ar lrdsis ↑
↓ Nec0 list ! & +capular /in#in# ! &
Other_________________________________________________________________________________________________
AD&s:________________________________________________________________________________________________
ROM/ Strength: ctive _____!"# Subcranial
R # R #
Cervical +3 _____ $ )i#htness _____ $ )i#htness
_____ $ _____ $Cervical !t% _____ $ )i#htness
_____ $ )i#htness _____ $ _____ $
Cervical $lex _____ $ )i#htness _____ $ _____ $
Cervical Ext _____ $ Di44iness _____ $ _____ $
A(A !t% _____ $ _____ $
Shoul%er:_____!"# Bilaterall&
ROM
R #
$lexin _____ $ _____ $
A3D _____ $ _____ $
E! _____ $ _____ $
I! _____ $ _____ $
1
UE M&oto'es: /N&
____________________________________
(ee) "ec* +le,or En%urance: ___________ 5secnds6
8/16/2019 Cervical Eval Form
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"a'e:_____________________________________________
(OB:_____________
+le,ibilit&: _____________________________________________________________________________________
$al)ation:
____________________________________________________________________________________
S)ecial Tests: 7pper &i#ament +ta'ility )ests
Cmpressin - Alar Odntid Inte#rity )est -
Distractin - )ransverse &i#% )est -
3rachial Plexus +.uee4e )est -
Neural )ensin R: - 3ias:________________
Active Passive
#: - 3ias:________________ Active Passive
+e#mental
mtin:______________________________________________________________________
7p #lide ↑ ↓
&catin:_________________________________________________________
D,n 1lide ↑ ↓
&catin:_________________________________________________________
"eurological Screen:
+ensatin:_____/N&
Other_____________________________________________________ !e8lexes:
3iceps !_____&_____ )riceps !_____&_____3rachiradialis
!_____&_____
Resting B$: ___ ( ____ Resting .R : _____
Treat'ent:__________________________________________________________________________________________________
____________________________________________________________________________________________________________
________________________________________________________________
SSESSME"T: _____ +ee Initial Evaluatin +ummary( Plan 8
Care ___________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Rehabilitation $otential: Excellent 1d $air Pr
ST/#T: _____ +ee Initial Evaluatin +ummary( Plan 8
Care
$#": 5Circle6 * !x( ,0______ 9 * ,0s______
Therex Strengthening
Stretching Joint Mobs Moist
Heat/ Cold Pack Bracing/ Taping Ultrasound
EStim Traction Mechanical /
Manual! Home Program Scapular Stab"
P#$M Manual Therap%
&ST'M $ther()))))))))))))))))))))))))))))))))))))))))))))))))))))))))))
Avg. Pain Rating _____ Self Reported Functional Rating
_____Neck
Disability Index _____
)herapist
+i#nature:__________________________________________________Date:_______________
)ime:______________
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