Cervical Evaluation Form

Patient Name Eval Date

Physician DOB
Therapist Next MD
visit

PERSONAL DATA
1. Temperature 2. BP (sitting):
>100° ? YES NO _________/
__________
3. Heart Rate: 4. Resp. Rate
__________bpm ______ per min

Pt History of Pain/Symptoms
1. Modified Oswestry Score: ______%  ≥ 75%  Stage I 40-60%  Stage II 20-40%
 Stage III ≤ 20%
2. Global Score: 3. Wadell Score: 4. FABQ Score:
5. Onset of Sx’s   Gradual  Sudden If sudden, was there a specific event/injury?
6. Pain Level  Current pain ____/10 Worst pain _____/10 Best
pain _____/10
7. Pain Type   Aching  Dull Tingling  Stabbing  Burning  Nauseating
Other:
8. Pain Location 
9. What relieves pain/Sxs?
(positions, movements meds, modalities)
10. What makes pain/Sxs worse?
(positions, movements, activities)
11. Pain/Sx’s. Frequency: 12. Duration of Pain/Sx’s: 13. Pain/Sx’s worse:
 Intermittent  Constant  < 16 days  > 16 days  In Morning  At Night
14. Symptoms below the IF YES  PERFORM LOWER QUARTER SCREEN
knee? IF NO  PERFORM SI/PELVIC ASSESSMENT
YES NO

UPER QUARTER SCREEN

Sensory Testing
Muscle Testing (Intact / Diminished /
Absent)

Right Left Right Left

C1
C2
C3
C4
C5
C6
C7
Special Tests: Positiv negative note
e
Adson’s Test:

Costoclavicular Test:

Modified Wrigh(Allen’s)Test:

Wright Test:

Roos Test:

Shoulder Girdle Passive

Elevation Test:

Cervical Compression Test:

Spurlings Test:

Cervical Distraction Test:

Bakody’s Sign:

ULTT 1:

ULTT 2:

ULTT 3:

ULTT 4:

Slump Test:

Valsalva’s Test:

Cervicogenic HA Test

Swallowing Test
ROM
Range Limited By
(Full or % Deviations?
(Pain, mm tightness, etc)
Limited)
Flexion
Extension
R SB’ing
L SB’ing
R Rotation
L Rotation

Sholder ROM
Range Limited By
(Full or % Deviations?
(Pain, mm tightness, etc)
Limited)
Flexion
Extension
R SB’ing
L SB’ing
R Rotation
L Rotation

NOTE
1-Scapula situation

2-Palpation:

Functional Tests: