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Patient Name _______________________________________________ Date ___________________

Patient Social Security # _________-______-_________

Complaints and Relevant Information From the History Form

______________________________________________________________________________________________________________________________________________________________________________

• If the patient’s complaints include pain, numbness or tingling into an extremity, then the patient is a candidate for an NCV and Vascular Study. Please fill out the Premier Patient Information form and fax it to Premier for Insurance Coverage Verification

Vascular Risk evaluation

*Have you ever suffered a stroke? Y N *Anyone in your family had a stroke Y N

Who / Age ____________________________________________________________________________

*Have you ever had a heart attack? Y N *Anyone in your family had a heart attack Y N

Who / Age ____________________________________________________________________________

*Do you have a vascular disease? Y N *Anyone in your family have a vascular dx Y N

Who / Age ____________________________________________________________________________

*Do you have high BP Y N *Anyone in your family have high BP Y N

Who / Age ____________________________________________________________________________

Do you smoke? Y N How much _______________ How long ___________

Have you ever smoked in the past? Y N When did you quit? ___________________________

Do you take birth control pills? Y N Have you ever taken birth control pills? Y N

• If the answer to any of the questions with a * is yes, then an upper vascular study should be performed prior to any cervical adjustments. If the majority of answers to any other questions (without the *) is yes, then a upper vascular study should be performed prior to cervical adj.

Blood Pressure Left _________/_________ Right _________/__________

Georges Test + - Deklyns Test + - Barre Leiou + -

• If any of these tests are + or there is a greater than 10mmHg difference in BP from one side to the other, then a upper vascular study should be performed prior to any cervical adjustment.

VITAL SIGNS

Height ____________ Weight ____________ Age __________ Sex ___________

-

POSTURE EVALUATION

|BODY PART |RT |LT |

|Head Tilt to the: | | |

|Head Rotation to the: | | |

|High Shoulder on the: | | |

|Shoulder Rotation to the: | | |

|High Pelvis on the: | | |

|Pelvic Rotation to the: | | |

_____ Anterior Head Carry

_____ Post. Pelvic Tilt

_____ Ant. Pelvic Tilt

CERVICO-THORACIC EXAMINATION

| |PAIN |SPASM |EDEMA |

|LEVEL |R |L |R |L |R |L |

|OCC | | | | | | |

|C1 | | | | | | |

|C2 | | | | | | |

|C3 | | | | | | |

|C4 | | | | | | |

|C5 | | | | | | |

|C6 | | | | | | |

|C7 | | | | | | |

|T1 | | | | | | |

|T2 | | | | | | |

|T3 | | | | | | |

|T4 | | | | | | |

|T5 | | | | | | |

|T6 | | | | | | |

|T7 | | | | | | |

|T8 | | | | | | |

|T9 | | | | | | |

|T10 | | | | | | |

|T11 | | | | | | |

|T12 | | | | | | |

CERVICOTHORACIC PALPATION

CERVICAL RANGE OF MOTION

PAIN/LEVEL

Flexion _____/60 ___________

Extension _____/75 ___________

Rt Lat. Flex _____/45 ___________

Rt Lat. Flex _____/45 ___________

Rt. Rot. _____/80 ___________

Lt. Rot _____/80 ___________

** REFLEX (If abnormal, then Consider NCV)

Reflex Grade

Biceps (C5) ________

Brachioradialis (C6) ________

Triceps (C7) ________

** SENSORY (If abnormal, thenConsider NCV)

|TEST |DEC |NORM |INC |

|Lateral Arm C5 | | | |

|Lateral Forearm, Thumb, Index Finger C6| | | |

|Middle Finger C7 | | | |

|Medial Forearm and Hand C8 | | | |

|Medial Brachial T1 | | | |

**CERVICAL / THORACIC ORTHOPEDIC

All + findings must describe location of provoked pain, radiation and intensity on a 1-10 scale

| |Location |Radiates to |Intensity |

|Cerv. Comp | | | |

|Max. Comp | | | |

|Cerv. Dist. | | | |

|Shld. Dep. | | | |

|Adsons | | | |

|Halsted | | | |

|Wrights | | | |

|Edens | | | |

|Valsalva | | | |

| | | | |

| | | | |

If any of these tests are positive, then the patient is a candidate for an NCV. Please fill out the Premier Patient Information Form and fax it to Premier

**CERVICAL MUSCLE TESTS

(If weak, then Consider NCV)

|TEST |GRADE |

|Deltoid C5 | | |

|Wrist Ext. C6 | | |

|Wrist Flexion C7 | | |

|Triceps C7 | | |

|Finger FlexionC8 | | |

|Interossei T1 | | |

OTHER DEVIATIONS

DOCTOR’S NOTES:

_________________________________________________________________________________________________________________________________________________________________________________________________________________________

DOCTOR’S NOTES:

_________________________________________________________________________________________________________________________________________________________________________________________________________________________

**LUMBAR MUSCLE TESTS

(If weak, then Consider NCV)

|TEST |GRADE |

|Dorsiflex and Invers. L4 | | |

|Big Toe Extension L5 | | |

|Foot Eversion S1 | | |

|Foot Plantar Flexion S1 | | |

|Heel Walk L4 | | |

|Toe Walk L5 | | |

**LUMBAR ORTHOPEDIC

All + findings must describe location of provoked pain, radiation and intensity on a 1-10 scale

| |Location |Radiates to |Intensity |

|SLR | | | |

|Braggards | | | |

|Well Leg | | | |

|Kemps | | | |

|Bechterew | | | |

|Valsalva | | | |

|Milgrims | | | |

|Lidners | | | |

| | | | |

| | | | |

| | | | |

If any of these tests are positive, then the patient is a candidate for an NCV. Please fill out the Premier Patient Information Form and fax it to Premier

** SENSORY (If abnormal, thenConsider NCV)

|TEST |INC |NORM |DEC |

|Below Ing. Lig L1 | | | |

|Mid. AnteroMed. Thigh L2 | | | |

|Anteromed. Thigh above knee L3 | | | |

|Anteromed. Thigh below knee L4 | | | |

|Lat. Leg, Dorsum foot, Med 3 toes L5 | | | |

|Lat foot, lat 2 toes, plantar foot S1 | | | |

** REFLEX (If abnormal, then Consider NCV)

Reflex Grade

Patellar L5 ________

Med. Hamstring L5 ________

Achilles S1 ________

LUMBAR RANGE OF MOTION

PAIN/LEVEL

Flexion _____/60 ___________

Extension _____/30 ___________

Rt Lat. Flex _____/25 ___________

Rt Lat. Flex _____/25 ___________

Rt. Rot. _____/30 ___________

Lt. Rot _____/30 ___________

THORACO-LUMBER PALPATION

| |PAIN |SPASM |EDEMA |

|LEVEL |R |L |R |L |R |L |

|T1 | | | | | | |

|T2 | | | | | | |

|T3 | | | | | | |

|T4 | | | | | | |

|T5 | | | | | | |

|T6 | | | | | | |

|T7 | | | | | | |

|T8 | | | | | | |

|T9 | | | | | | |

|T10 | | | | | | |

|T11 | | | | | | |

|T12 | | | | | | |

|L1 | | | | | | |

|L2 | | | | | | |

|L3 | | | | | | |

|L4 | | | | | | |

|L5 | | | | | | |

|S1 | | | | | | |

|RT. PSIS | | | | | | |

|LT. PSIS | | | | | | |

Thoraco-lumbar EXAMINATION

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