Pt Eval Sheet for C-Spine

Cervical Spine Evaluation
Name:__________________ NDI____________________ 9 points = relevant change
Age:_________ PMH:___________________________

Previous Episode:______________________________ Occupation:______________________

Current Medications:________________________ Reason for PT:________________________

Have you had recent diagnostic imaging? Y N _____________________ MOI / When and How did you first notice your pain? ________________________________

Do you do something?_________________________________________

What Functional Limitations do you have: Sitting___________ Sleep__________ Reaching_________

ADL(brush, dress, Hair)________ ___________________ Work Responsibilities Y N

Transfers_____________________________ Hobbys__________________________________

Pain/Symptom Assessment:
Please point to where your pain is on your body? What words would you use to describe your pain?

Sharp Pain (nerve) Deep (bone) Diffuse/Aching (vascular) Dull(muscle)

NPRS in the last 72 hours: Best:_____________ /10 Worst_____________/10

NPRS Start of Exam:___________/10 Finish:___________/10

Is there any position that relieves your pain?__________________________________________

What is your goal for PT?__________________________________

Any other medical condition not mentioned?_______________________________________

Red Flags/Vitals: MED REFFERALS
Any Difficulty Swallowing? Y N
Any Increased Pain at night or night sweats? Y N
Any Changes in Sight, Smell Vision or Balance? Y N
Hx of CVD or pain in chest? Y N
Upper GI Tract or Abs pain? B/B changes? Y N
SOB, increase WOB or Hx of Pul disease? Y N

VBI –