Neck Pain Mds_24 Jul 07

Cervical Form Examined by: Licensed PT Student PT Both Licensed PT Student PT Both Demographics & History (Initial Only) Patient ID: Total duration of symptoms (yrs): Date (Initial): Location (check all that apply): Neck Thorax Arm above elbow ( Bilat Uni) Arm below elbow ( Bilat Uni) Head ( Bilat Unilat) Duration current episode (days):__________ FABQ (modified for neck) PA______ WK________

Gender:

Female

Height: ____ ft ____ in (lb):______ Age:

Wt

Other signs/symptoms/conditions (check all applicable): N/A Thoracic Spine Hypertension: BP _____ / ______ Upper Extremity(ies) Hip(s) Diabetes Knee(s) Foot/Feet Pulmonary Conditions/Disease Back Pain Shoulder Pain Obesity Headache Dizziness/Light Headedness Depression Hemifacial Sxs ** Smoking (circle): Current smoker / Smoked in past / Never Smoked Medications For: Cardiac Cholesterol Vascular Depression Diabetes Shoulder Pain Other musculoskeletal pain Other_______________ Post surgical? Yes No Previous episodes of neck pain: 0 1-2 3-5 >5 Sought medical care for this same Frequency increasing? Yes No episode in the past? Yes No Is this injury due to whiplash? Yes No

PHYSICAL EXAM: (Initial Only) Upper limb tension: + — Spurling’s: + Not Indicated Distraction: + Not Indicated Cervical rot<60o: + Deep neck flexor endurance (secs): _______ Cervical rotation lateral flexion: + -

Male

Treated by:

Posture: Flat upper t-spine Increased kyphosis upper t-spine Normal

Cervical ROM: Flex:____ Ext:____ SBR:____ SBL:____ RR:____ LR:____

Centralization: Centralizes Cannot centralize Not applicable

Dermatomes (C5T1) Normal Abnormal Not Indicated If abnormal, which dermatome(s) (circle): C5 C6 C7 C8 T1

Myotomes (C5-T1) Normal Abnormal Not Indicated If abnormal, which myotome(s): (circle) C5 C6 C7 C8 T1

Reflexes: C5: Nl Dec Inc C6: Nl Dec Inc C7: Nl Dec Inc Not Indicated

1

Interventions 2 3 4

Initial / Wk 1

2 Wk

3 Wk

4 Wk

5 Wk

6 Wk

D/C

A. Patient Education/Instruction B. Mobility Exercises-Cervical C. Mobility - Thoracic Spine/Rib Cage D. Thrust Manipulation Cervical E. Thrust Manipulation - Tx / Rib Cage F. Non-thrust maniplation/mobilization-Cx G. Non-thrust manip/mobilization-Tx/Rib H. Repeated Retraction Exs (McKenzie)

Classification (circle one) Mobilization Centralization Pain Control Endurance Mobilization Centralization Pain Control Endurance Mobilization Centralization Pain Control Endurance Mobilization Centralization Pain Control Endurance Mobilization Centralization Pain Control Endurance Mobilization Centralization Pain Control Endurance Mobilization Centralization Pain Control Endurance

NPRS (0-10) Avg past 24 hrs

NDI

HA Exercise & HA Exercise & HA Exercise & HA Exercise & HA Exercise & HA Exercise & HA Exercise &

I. Aerobic Exercise J. General Conditioning Exercises K. Muscle Flexibility - Cervical Muscles L. Muscle Flexibility Scapular/Chest M. Cold Modalities N. Thermal Modalities O. Traction— Mechanical/Manual (circle) P. Behavioral Exercise Approach

Q. Neck Flexor Strengthening R. NMES (Strengthening) S. NMES (Pain Control) T. Soft Tissue Massage U. Myofascial Release V. Craniosacral Therapy W. Other_______________ __ X. Other_______________ ___

Date of Last Visit: ______/_______/_______ Duration of Care To Date (days):____________ Is the last visit the discharge visit: Yes / No Number of Visits To Date: