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    Cervical Assesment

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    ahmadkiblawi884
    This document contains a cervical evaluation form for a patient, including sections on personal data, pain history, symptoms, special tests, range of motion, and notes. It collects information on the patient's temperature, blood pressure, heart rate, respiratory rate, pain levels, pain characteristics, aggravating and relieving factors, and results of orthopedic tests to evaluate the cervical spine, shoulders, and neurological function. The form aims to comprehensively assess the patient's cervical condition through physical exam and patient-reported outcomes.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Cervical Assesment

    Uploaded by

    ahmadkiblawi884
    51 views3 pages
    This document contains a cervical evaluation form for a patient, including sections on personal data, pain history, symptoms, special tests, range of motion, and notes. It collects information on the patient's temperature, blood pressure, heart rate, respiratory rate, pain levels, pain characteristics, aggravating and relieving factors, and results of orthopedic tests to evaluate the cervical spine, shoulders, and neurological function. The form aims to comprehensively assess the patient's cervical condition through physical exam and patient-reported outcomes.

    Original Description:

    examination sheet with specific test for cervical pain

    Original Title

    cervical assesment

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    This document contains a cervical evaluation form for a patient, including sections on personal data, pain history, symptoms, special tests, range of motion, and notes. It collects information on the patient's temperature, blood pressure, heart rate, respiratory rate, pain levels, pain characteristics, aggravating and relieving factors, and results of orthopedic tests to evaluate the cervical spine, shoulders, and neurological function. The form aims to comprehensively assess the patient's cervical condition through physical exam and patient-reported outcomes.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    51 views3 pages

    Cervical Assesment

    Uploaded by

    ahmadkiblawi884
    This document contains a cervical evaluation form for a patient, including sections on personal data, pain history, symptoms, special tests, range of motion, and notes. It collects information on the patient's temperature, blood pressure, heart rate, respiratory rate, pain levels, pain characteristics, aggravating and relieving factors, and results of orthopedic tests to evaluate the cervical spine, shoulders, and neurological function. The form aims to comprehensively assess the patient's cervical condition through physical exam and patient-reported outcomes.

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    © All Rights Reserved
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    Cervical Evaluation Form

    Patient Name Eval Date


    Physician DOB
    Therapist Next MD
    visit

    PERSONAL DATA
    1. Temperature 2. BP (sitting):
    >100° ? YES NO _________/
    __________
    3. Heart Rate: 4. Resp. Rate
    __________bpm ______ per min

    Pt History of Pain/Symptoms
    1. Modified Oswestry Score: ______%  ≥ 75%  Stage I 40-60%  Stage II 20-40%
     Stage III ≤ 20%
    2. Global Score: 3. Wadell Score: 4. FABQ Score:
    5. Onset of Sx’s   Gradual  Sudden If sudden, was there a specific event/injury?
    6. Pain Level  Current pain ____/10 Worst pain _____/10 Best
    pain _____/10
    7. Pain Type   Aching  Dull Tingling  Stabbing  Burning  Nauseating
    Other:
    8. Pain Location 
    9. What relieves pain/Sxs?
    (positions, movements meds, modalities)
    10. What makes pain/Sxs worse?
    (positions, movements, activities)
    11. Pain/Sx’s. Frequency: 12. Duration of Pain/Sx’s: 13. Pain/Sx’s worse:
     Intermittent  Constant  < 16 days  > 16 days  In Morning  At Night
    14. Symptoms below the IF YES  PERFORM LOWER QUARTER SCREEN
    knee? IF NO  PERFORM SI/PELVIC ASSESSMENT
    YES NO

    UPER QUARTER SCREEN

    Sensory Testing
    Muscle Testing (Intact / Diminished /
    Absent)

    Right Left Right Left


    C1
    C2
    C3
    C4
    C5
    C6
    C7
    Special Tests: Positiv negative note
    e
    Adson’s Test:

    Costoclavicular Test:

    Modified Wrigh(Allen’s)Test:

    Wright Test:

    Roos Test:

    Shoulder Girdle Passive


    Elevation Test:

    Cervical Compression Test:

    Spurlings Test:

    Cervical Distraction Test:


    Bakody’s Sign:

    ULTT 1:

    ULTT 2:

    ULTT 3:

    ULTT 4:

    Slump Test:

    Valsalva’s Test:

    Cervicogenic HA Test

    Swallowing Test
    ROM
    Range Limited By
    (Full or % Deviations?
    (Pain, mm tightness, etc)
    Limited)
    Flexion
    Extension
    R SB’ing
    L SB’ing
    R Rotation
    L Rotation

    Sholder ROM
    Range Limited By
    (Full or % Deviations?
    (Pain, mm tightness, etc)
    Limited)
    Flexion
    Extension
    R SB’ing
    L SB’ing
    R Rotation
    L Rotation

    NOTE
    1-Scapula situation

    2-Palpation:

    Functional Tests:

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