Eval form - RehabEdge
Cervical EvaluationName______________________________ DX______________________________________________ Date:_____________Current Meds___________________________________________________________________________________________PMH__________________________________________________________________________________________________Physician_______________________________Next Appt___________________Onset_______________Initial Evaluation:_____ Re-Evaluation:_____Pain Rating_________Funct. Rating__________SUBJECTIVE: Radiating pain R L___________________Numbness/ Tingling R L ______________________ Trouble sleeping _____# Hours/ night_____ Symptoms worse in A.M. P.M. Headaches: Y N Frequency:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________C/c:____________________________________________________________________________________________________Occupation/Social Hx:_____________________________________________________________________________________ Work Duties:____________________________________________________________________________________________Pt. Goals:_______________________________________________________________________________________________OBJECTIVE:Observation:_____WNL_____Rounded shoulders_____Forward headmid-Thoracic Kyphosis upper Thoracic Kyphosis Lumbar lordosis Neck list R LScapular Winging R LOther_________________________________________________________________________________________________ADLs:________________________________________________________________________________________________ROM/ Strength: Active_____WNLSubcranialR LRLCervical SB_____ P Tightness_____ P Tightness_____P_____ PCervical Rot._____ P Tightness_____ P Tightness_____P_____ PCervical Flex_____ P Tightness_____ P_____ PCervical Ext_____ P Dizziness_____ P_____ PA/A Rot._____ P _____ PUE Myotomes: WNL ____________________________________Shoulder:_____WNL BilaterallyAROMRLDeep Neck Flexor Endurance: ___________ (seconds) Flexion_____ P _____ PABD_____ P _____ PER_____ P _____ PIR_____ P _____ PName:_____________________________________________ DOB:_____________Flexibility:_____________________________________________________________________________________Palpation:____________________________________________________________________________________Special Tests:Upper Ligament Stability TestsCompression+Alar Odontoid Integrity Test+ Distraction+Transverse Lig. Test+ Brachial Plexus Squeeze Test + Neural Tension R:+ Bias:________________Active PassiveL:+ Bias:________________Active PassiveSegmental motion:______________________________________________________________________Up glide Location:_________________________________________________________Down Glide Location:_________________________________________________________ Neurological Screen:Sensation:_____WNLOther_____________________________________________________Reflexes:Biceps R_____L_____Triceps R_____L_____Brachioradialis R_____L_____Resting BP: ___ / ____ Resting HR: _____Treatment:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ASSESSMENT:_____See Initial Evaluation Summary/ Plan of Care ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Rehabilitation Potential:Excellent Good Fair PoorSTG/LTG:_____ See Initial Evaluation Summary/ Plan of Care PLAN:(Circle) # Rx/ wk______~ # wks______ Therex Strengthening Stretching Joint Mobs Moist Heat/ Cold Pack Bracing/ Taping Ultrasound EStim Traction (Mechanical / Manual) Home Program Scapular Stab. PROM Manual Therapy ASTYM Other:___________________________________________________________Avg. Pain Rating _____Self Reported Functional Rating _____Neck Disability Index: _____Therapist Signature:__________________________________________________Date:_______________ Time:______________ ................
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