Name:________________
Cervical Initial Evaluation
DOB/Age:_____________
Referring Physician:_________________
Date:_________
HPI:
Current symptoms:__________________________________________________________________________________
Duration of symptoms: _______________________________________________________________________________
Sleeping position and quality/# of pillows:___________________________________________
Diagnostic Testing: _____________________________________________________________
Mechanism of Injury: ____________________________________________________________
Previous Treatments: ________________________________________________________________________________
Pain: current: ___/10
best: ___/10
worst: ___/10
Where? (distal to shoulder?) ______________________________________________________________________________________________
What does pain feel like? _____________________________________________________________________________
What worsens pain or other symptoms?_______________________________________________________________________________
What makes pain or other symptoms better?______________________________________________________________
PMHx: ___________________________________________________________________________________________
Goals:____________________________________________________________________________________________
__________________________________________________________________________________________________
Meds: ____________________________________________________________________________________________
O: Neck Disability Index: _______
Cervical AROM (* if repro.pain)
FABQPA _________
Cervical AROM
(Denote BG/UG)
Extension ______
Flexion
______
R Rotation ______
L Rotation ______
R SB
______
L SB
______
Joint Mobility Testing
Cervical Mobility (Central)
C2 _______
C3 _______
C4 _______
C5 _______
C6 _______
C7 _______
T1 _______
T2 _______
T3 _______
T4 _______
T5 _______
T6 _______
(* if repro. Pain)
Thoracic AROM (* if repro. pain)
Thoracic PROM
Extension ______
Flexion
______
R Rotation ______
L Rotation ______
(* if repro. Pain)
Is Flexion limited?
Y/N
If yes, clear C-T junction.
Is Neuro exam indicated? Y/N
Joint Mobility Testing
Cervical Downglides (R/L)
C2 ________/________
C3 ________/________
C4 ________/________
C5 ________/________
C6 ________/________
C7 ________/________
(* if repro. Pain)
Rib Mobility (R/L)
Rib 1 ________/________
Rib 2 ________/________
Rib 3 ________/________
Rib 4 ________/________
Rib 5 ________/________
Rib 6 ________/________
(* if repro. Pain)
Shoulder Screen:_____________________________
___________________________________________
___________________________________________
___________________________________________
Special Tests
Pain Provocation: Max Close Y/N (L or R)
Max Opening: Y/N (L or R)
MIDAS _____________
Vertebral Artery
Alar Ligament
Sharp-Purser Test
Results (note side)
Name:
MMT:
Cervical Flexion
Shoulder Elevation
Shoulder Abduction
Elbow Flexion
Wrist Extension
Wrist Flexion
Elbow Extension
Finger Adduction
Finger Abduction
R/L
__/__
__/__
__/__
__/__
__/__
__/__
__/__
__/__
__/__
Light Touch
Cervical IE
Right /
DOB:
Reflexes (R/L)
Left
C2- Suboccipital
_________/__________
C3- Anterior Neck _________/__________
C4-Acromion process ________/__________
C5-Lateral Brachium _________/__________
C6- Lateral Forearm _________/__________
C7-3rd Digit
_________/__________
C8-5th Digit
_________/__________
T1- Medial Forearm _________/__________
T2-Medial Brachium _________/__________
Biceps
_____/______
Bracioradialis _____/______
Triceps
_____/______
(N=Normal, D=Diminished, A=Absent)
If Radicular Symptoms,
Compression
Distraction
Results (R/L)
/
/
/
/
/
/
Shoulder ABD sign
T1 Nerve Root Stretch
Spurling A
ULTTA
Thoracic Outlet Screen : ____________________________________________________________________________
Neural Tension Tests
Median Nerve
Ulnar Nerve
Results (R/L)
/
/
/
Radial Nerve
Other Special Tests_________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Postural Observation: (kyphosis, scoliosis) _______________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Does pt have diminished thoracic kyphosis? Y/N
Palpation/ Soft Tissue Assessment: ___________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Clinical Prediction Rules to Guide Treatment Decisions
Symptoms
Indications
Treatments
Neck pain:
Predicts response to thoracic
manipulation
 Symptoms <30 days
 No symptoms distal to shoulder
 Looking up does not aggravate
symptoms
 FABQPA score <12
 Diminished upper thoracic
kyphosis
 Cervical Extension ROM <30º
 ULTT A increases symptoms
 Involved cervical rotation <60º
 Distraction relieves symptoms
 Spurling A increases
symptoms
Seated thoracic distraction
manipulation 2x
Supine upper thoracic manipulation
2x
Supine middle thoracic manipulation
2x
Cervical ROM using 3 fingers
Cervical Radiculopathy:
Predicts accurate diagnosis of
cervical radiculopathy
Cervical lateral glides in neural
stretch
Thoracic spine mob/manip
Deep neck flexor and scapular
strengthening
Mechanical Traction
(91% of patients with 4 pos. tests improved
with these treatments)
Likelihood
ratio
>5+ = 100%
4+ = 93%
3+ = 86%
2+ = 71%
1+ = 58%
# of indic____
4+ = 90%
3+ = 65%
2+ = 21%
# of indic____
Name:
Cervical IE
DOB:
Assessment:_______________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
STG:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
LTG:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Plan:_____________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
_______________________________________________
Signature
____________________
Date