THORACIC EVALUATION FORM
Patient Name
Physician
Therapist
Eval Date
DOB
Next MD visit
PERSONAL DATA
1. BP (sitting):
_________/__________
2. Heart Rate:
__________bpm
3. Resp. Rate
______ per min
Pt History of Pain/Symptoms
4.
Age:
6.
Onset of Sx’s   Gradual
7.
Pain Location 
8.
Pain Level 
9.
Pain Type   Aching
 Dull
10.
Radiating pain   Yes
 No
11.
What relieves pain/Sxs?
5.
 Sudden
Occupation:
If sudden, was there a specific event/injury?
Current pain
____/10
Worst pain _____/10
Tingling
 Stabbing
 Burning
Best pain
 Nauseating
_____/10
Other:
If yes, where to?
(postures, movements meds, modalities)
12. What makes pain/Sxs worse?
(postures,, movements, activities)
13. Does pain occurs with:  Inspiration
14. Difficulty breathing? 
 Yes
 Expiration
 Both
 No
15. Is the pain affected by coughing, sneezing, or straining?   Yes
16. Is the condition 
 Improving
 Getting worse
17. Any paresthesia or abnormal sensation? 
18. Any problems with digestion? 
 Yes
19. Any skin abnormalities in thorax area? 
 Yes
 No
 Yes
 No
 Staying the same
 No
If yes, where?
If yes, what kind?
 No
If yes, what kind?
Other:
Patient’s Goals:
Observations
 Round back
 Hump back
 Flat back
 Kyphosis
 Razorback spine
 Dowager’s hump
 Funnel chest
 Barrel chest
 Pigeon chest
 Forward head
 Rounded shoulders
 Scoliosis
20. Breathing pattern:
21. Quality of respiration:
22. Effort required to inhale/exhale:
23. Coughing/Noisy/Abnormal breathing patterns?:
Thoracic AROM/PROM:
L
L
Reproduction of Symptoms:
Shoulder ROM Screen
L
(With overpressure)
Flex
Flexion _____________________
Extension ___________________
R SB _______________________
L SB _______________________
R Rot ______________________
L Rot ______________________
R
Flex
Ext
IR
ER
ABD
HADD
R
________ ________
________ ________
________ ________
________ ________
________ ________
________ ________
Cervical ROM (i.e. full and pain-free)
Flex_________________
Ext_________________
R SB________________
L SB________________
R Rot________________
L Rot________________
Ext
Palpation/Soft Tissue Assessment:
Thoracic Spring Testing (note if Normal, Hyper, or Hypo)
T1
T2
T3
T4
T5
T6
T7
T8
T9
T10
T11
T12
Central
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
R Unilateral
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
L Unilateral
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
Scapulo-Humeral Rhythm:
Manual Muscle Tests
Finger ABD (T1) ___________________
Abdominals _______________________
Paraspinals ________________________
Neck Extensors ____________________
Neck Lat Flexors ___________________
R Rib
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
L Rib
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______
Cervical
C1 _______
C2 _______
C3 _______
C4 _______
C5 _______
C6 _______
C7 _______
Lumbar
L1 _______
L2 _______
L3 _______
L4 _______
L5 _______
Special Tests (Neurodynamic):
Slump Test: _______________ T1 Nerve Root Stretch: ____________
Kernig’s Sign: _____________ Ulnar Nerve Testing: _____________
SLR: ____________________ Beevor Sign:____________________
Other: ___________________
Scapular Manual Muscle Tests
Upper Trap: R________ L________
Middle Trap: R________ L________
Lower Trap: R________ L________
Rhomboids: R________ L________
Serratus Ant: R________ L________
Thoracic General Dermatomes:
• T1: Medial Forearm
• T2: Medial Arm
• T4-6: Pain around Nipple
• T7-T8: Pain in epigastriac area
• T9-T11: Pain in umbilical area
• T12: Pain in the groin
Thoracic Manipulation Indications:
• Assymetric Thoracic/Rib motion restriction
(passive & active)
• Point tenderness
• Pain with inhalation
• Acute Complaints – not long standing
• Muscle guarding upon palpation
• Shoulder girdle pain, but Shoulder ROM not limited
• No Rib or Thoracic Spine fracture
• No Manip Contraindications (Paget’s, RA, Osteomyelitis, CA,
Ankylosing Spondylitis, Cord/Cauda Equina Syndrome, Vertebral Artery involved)
Use Clinical Judgement to determine if Manip is Indicated
(check which perfomed):
• Thoracic (wedge) Manip
• Rib (screw-home) Manipulation
• Upper Thoracic Manipulation (Seated, hands behind neck)
Audible Pop? • Yes • No
Symptoms Post-Manip? _______________________
___________________________________________
______________________________________________
*If Manip performed, complete f/u Thoracic stretching
Cervicothoracic Manipulation for Neck Pain
• Symptoms <30 days
• No symptoms distal to the shoulder
• Looking up doesn’t aggravate symptoms
• FABQ-PA <12
• Diminished upper thoracic kyphosis
• Cervical Extension ROM < 30º
Liklihood Manip Success:
+5 or 6 = 100%
+4 = 93%
+3 = 86%
+2 = 71%
+1 = 58%
CT Manip Performed? • Yes • No
(seated, hands behind neck)
Audible Pop? • Yes • No
Symptoms Post-Manip? ___________
_______________________________
Other Possible Thoracic Issues:
• Osteoporotic Wedge Fracture
• Thoracic Outlet Sydrome (must have symptom recreation for positive test)
• Roos Test
• Adson Maneuver
• Halstead Maneuver
 Dowager’s Hump
 Scheuermann’s Disease Kyphosis
• Scoliosis: Convexity: ________ Levels: ____________________
• Long Thoracic Nerve Palsy
• Costochondritis: most common ages 10-21, no PT Rx
• T4 Syndrome: treat with T4 region mob/manip
pain with deep breathing
pain brought on by exercise
chest pain (esp ribs 4-6)
costochondral TTP
UE symptoms
• pain
Non-dermatomal distribution
Lack of hard neuro signs
Headaches
• yes
• yes
• yes
• yes
• no
• no
• no
• no
• parasthesia
• yes
• yes
• yes
• none
• no
• no
• no
ASSESSMENT:
SHORT TERM GOALS:
1.
2.
3.
LONG TERM GOALS:
1.
2.
3.
PLAN:
Signature___________________________________________________________ Date__________________________