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YOUR COMPANY NAME

E-mail Form

123 Sunshine Lane, Any town, USA, 10001

Tel: 310-111-1111 Fax: 310-222-2222

Print Form

NPI #

CERVICAL EXAM FORM

PATIENT INFORMATION
Last Name John

MI W

First Name Smith

Bpm

Breathing 15

SSN # 123-45-6789

Date of Birth 12/15/1969

VITALS
BP 120/80

Pulse 80

mmHg

Temperature 98.7

Rpm

Height 68

Weight 160

in

INSPECTION, PALPATION AND PERCUSSSION

+2 Tenderness over spinous process of C6 and C7

Findings

RANGES OF MOTION
Flx 20 degrees

Ext 10 degrees

RLF 20 degrees

LLF 20 degrees

RR 80 degrees

LR 90 degrees

ORTHOPEDIC EXAMS
-

Valsalva

BL

Finding

George's Screening Procedure

BL

Finding

Distraction

BL

Finding Patient has relieve of symptomes

Maximal Foraminal Compression

BL

Finding

Vertebrobasilar Artery Function

BL

Finding

DEEP TENDON REFLEXES

(L) Biceps (C5)

2+

(L) Brachioradialis (C6)

2+

(L) Triceps (C7)

2+

(R) Biceps (C5)

2+

(R) Brachioradialis (C6)

2+

(R) Triceps (C7)

2+

MYOTOMES & DERMATOMES

Neck Extensors (C1-C3)

5/5

(L) Deltoid, Biceps (C5)

5/5

(L) Wrist Extensors, Radiobrachialis (C6)

5/5

Neck Flexors

5/5

(R) Deltoid, Biceps (C5)

5/5

(R) Wrist Extensors, Radiobrachialis (C6)

5/5

(L) Finger Flexion (C8)

5/5

(L) Finger Abduction (T1)

5/5

(L) Wrist Flexors,Triceps, Finger Extension(C7)

5/5

(R) Finger Flexion (C8)

5/5

(R) Finger Abduction (T1)

5/5

(R) Wrist Flexors,Triceps, Finger Extension(C7)

5/5

Dermatomes

(C2-C3)

Pinwheel examination is normal bilateral

Provider Name Austin Inge

Title

D.C.

Date Apr 12, 2007

Copyright 2007 Med-e-Forms Inc. All rights reserved. www.Med-e-Forms.com

Provider Signature

lbs