C-SPINE T-SHEET
CC:
Neck Pain R 
Upper Extremity Pain R 
HPI:
Onset:
Mechanism of injury:
Location:
Radiation:
Yes 
Pain at Rest: Yes 
Exacerbating factors:
Relieving factors:
L 
L 
No 
No 
ROS:
Fever  Chills 
Weakness  Night Pain 
PMHx:
Meds:
Allergies:
Chronic medical conditions:
Immunizations Current:
Both 
Both 
Where:
Where:
Numbness  Paresthesias 
Weight Loss 
Amount_________
Yes  No 
Soc Hx:
Occupation and/or Activities:
Smoking status: Current  Past  Never 
IV Drug Use:
Yes  No 
PE:
Vital Signs:
BP:
P:
Wt:
BMI:
RR:
General Appearance:
Skin:
Vascular:
Neuro:
ROM:
Soft Tissue:
(Palpation)
Redness
Yes 
Warmth
Yes 
Ecchymosis Yes 
Deformity
Yes 
Ulcers
Yes 
Distal Hair pattern:
No 
Location:
No 
Location:
No 
Location:
No 
Location:
No 
Location:
Normal  Decreased 
Right
Capillary Refill:
Radial Pulse:
Left
Nl  Abnormal 
Nl  Abnormal 
Spurling’s Maneuver:
Nl  Abnormal 
Nl

Absent     
Brachioradialis Reflex (C5):
Bicep Reflex (C6): Nl  Absent     
Tricep Reflex (C7): Nl  Absent     
Hoffman Test:
Nl  Abnormal 
Babinski Reflex:
Nl  Abnormal 
Position Sense:
Nl  Abnormal 
Nl  Abnormal 
Nl  Abnormal 
Nl  Abnormal 
Nl  Absent     
Nl  Absent     
Nl  Absent     
Rotation: Nl    Painful 
Flexion: Nl    Painful 
Extension: Nl    Painful 
Tenderness: Yes  No  Location:
Vertebral Tenderness: Yes  No 
Cervical Lymphadenopathy: Yes  No 
Location:
Location:
Nl  Abnormal 
Nl  Abnormal 
Nl  Abnormal 
Nl    Painful 
Nl    Painful 
Nl    Painful 
TREAT APPROPRIATELY
TREAT WITH CLOSE
FOLLOW-UP
Cervical Myelopathy ............................................. 721.1
Degenerative Disc Disease .................................... 722.4
Mechanical Pain/Benign Neck Pain ...................... 723.1
Mild Radicular Symptoms .................................... 723.4
Whiplash Associated Disorder .............................. 847.0
Severe pain
Narcotics prescribed
(< 1 week f/u)
CALL CONSULTANT
THAT DAY
CONSULT
OR
REFER
Fracture
X-ray negative, but tender bony prominence or neurologic signs
Meningitis
Suspect myelopathy
Other positive X-ray findings
History of C-spine surgery with recurrent symptoms
Plan:
 Xray / imaging
 Laboratory eval
 NSAIDs
 Acetaminophen
 Other
 PRICE Protocol
 Physical Therapy
Disposition:
 Treatment initiated: Follow-up __________ weeks
 Treatment / work up initiated: Follow-up ≤ 1 week __________ days
 Immediate call to Dr.
 Consultation initiated with Dr.
 Referral to Dr.