Patient Name: Referring Physician: Date of Onset: CC: MOI:

Age:

Examination: History: LOC: Head trauma: Headaches: Onset of Sx: Location of pn: Characteristics of pn: Vision changes: Swallowing Difficulties: Glasses: Sleeping position: Visual Observation: Head: Cervical Spine : Spine: Precautionary Tests: Vertebral Artery Dizziness Transverse Ligament Lateral Shear SB & Rot Alar Ligament Sharp Pursers POS NEG

Joint Clearing: TMJ: Shoulder Complex: Elbow: Wrist: T-Spine: ROM: Cervical Spine MVMTS AROM Flex Ext SB Rot Resisted Tests: Isometric MVMTS Mid Flex Ext SB Rot Neurological Myotomes Strong C1/C2 C4 C6 C8 Weak

PROM

END-FEEL

PAIN

Lengthened

Shortened

Strong/Weak Pnfl/Pnlss

Strong C3 C5 C7 T1

Weak

Sensory: Light Touch:

Pin Prick:

Reflexes: Jaw: Biceps: Brachialis: Triceps

1+

2+

3+

4+

Special Tests: Spurlings General Foraminal R L Maximal R L Distraction Arm ABD R L ULTT General R L Median R L Ulnar R L Radial R L Slump Test R L Valsalva

Pos

Neg

TOS tests ROOS Adsons R L

Costoclavicular R L

Pos

Neg

Modified Wright R L Right Hyper ABD TOS Relief Resisted Tests Flexion: Ant Lat Flex: R: L: Post Lat Ext: R: L: Joint Play Side to Side: A/P Glide: Distraction: ROT of Head on C1: Central PA: Grade

Unilateral PA: Palpation Supine: Ant:

Post: Sitting: Ant:

Post: Functional Tests: