Pt Eval Sheet for C-Spine

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  • Topic: Vertebral column, Cervical vertebrae, Thoracic vertebrae
  • Pages : 3 (380 words )
  • Download(s) : 115
  • Published : March 28, 2013
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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


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 –...
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