Neck/ Cervical Spine Patient Evaluation

NECK/ CERVICAL SPINE PATIENT EVALUATION

REFERRED BY:______NAME:______Age:__

Type of Onset: □ gradual □ sudden □ no injury □ injury
Date of onset: ______(If you can’t remember exactly, please guess to the nearest date month or year.)

Did you go to an emergency department? □no □yes, When?Name:______

How, when, and what happened?

______

Have you had a similar problem in the past? If so, describe:

CURRENT STATUS:

Severity: □ mild □ moderate □ severe □ incapacitating

Frequency: □ constant □ intermittent □ daily □ weekly □ monthly

Location of Pain: □head (right/left/both) □scalp (right/left/both) □anterior neck (right/left/both)

□posterior neck (right/left/both)□top of shoulder (right/left/both) □ arm (right/left/both) □ upper back (right/left/both) □ scapula (right/left/both) □ interscapular (right/left/both) □ mid back (right/left/both)

□ chest (right/left/both) □ Other

Does the pain extend/radiate anywhere else?: □no □yes, Where? □Outside of (right/left/both) shoulder
□Thumb of (right/left/both) hand □Middle (long) finger of (right/left/both) hand □ Small (pinkie) finger of (right/left/both) hand □outer (right/left/both) axilla (armpit) Other:

Quality:□aching □burning □discomforting □dull □ gnawing □lancinating □piercing □sharp

□shooting □stabbing □throbbing □tingling □electrical shock □Other: ______

What makes the symptoms/ pain worse?: □nothing □bending □climbing stairs □coughing □defecation □driving □exertion □ flexion □ hyperextension □kneeling □lifting □lying down □prolonged sitting

□pushing □rotation □running □sneezing □standing □stooping □straining □stress □turning head □twisting □Valsalva □walking □working □Other:______

What things help you feel better?: □Nothing □cold/ice □heating pad □ice □massage □exercise □rest □sitting □standing □stretching □twisting □walking □cervical collar □cervical traction □physical therapy □acupuncture/TCM □osteopath or chiropractic manipulation □injection □muscle relaxation/medication

□other

Any change in bowel or bladder function? □ No □ Yes, What: ______

Any problems with balance or steadiness? □ No □ Yes, What: ______

Associated Symptoms: □bladder dysfunction not spinal related □numbness □tingling □tenderness

□weakness □bowel dysfunction not spinal related □dysphagia (difficulty swallowing) □incoordination (clumsiness) □muscle atrophy □muscle spasm □numbness □other join pain □rash □sexual dysfunction

□sexual dysfunction not spinal related □other______

What activities do your symptoms prevent you from doing? ______

What has been done so far?

□ Surgery (type, doctor, and date): ______

□ X-rays and Date: ______

□ MRI and Date: ______

□ EMG and Date: ______

□ Other diagnostic testing and Date: ______

□ Injections: ______Relief felt: □None □Minimal □Moderate □Significant

□ Physical Therapy: ______Relief felt: □None □Minimal □Moderate □Significant

□ Brace (Describe): ______Relief felt: □None □Minimal □Moderate □Significant

□ Medication taken for this problem: ______

During the last month, how frequently did you take medications for pain?

□Never □Daily □Several times a week □About once a week □Less than once a week

How much did medication help? □Complete relief □Moderate relief □Very little relief □No relief