Cervical Spine Evaluation
NDI____________________ 9 points = relevant change Age:_________
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
Please point to where your pain is on your body? What words would you use to describe your pain?
Sharp Pain (nerve) Deep (bone)
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?
Upper GI Tract or Abs pain? B/B changes?
SOB, increase WOB or Hx of Pul disease?
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