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Place your header here Initial Evaluation and Treatment Plan- Cervical/Thoracic Evaluation Date of Eval: ____________ Place Label Here Date of Onset:____________ Diagnosis: ________________________________________ History/Mechanism of Injury: _____________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Psychosocial/Functional Deficits: __________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ PMH: _________________________________________________________________________________ ______________________________________________________________________________________ Current Medications: ____________________________________________________________________ ______________________________________________________________________________________ Symptomology: Constant_____ Intermittent_____ Variable_____ Unchanging _____ Daily _____ or symptoms with activities _______________________ or symptoms with positions _______________________ Pain Pattern/Intensity (0-10 scale): Rest______ Activity______ Comments: __________________________________________ ___________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ Observation/Inspection: _______________________________ ___________________________________________________ ___________________________________________________ Joint Clearing: _______________________________________ ___________________________________________________ Sketch location of pain here AROM PROM Resistance Cervical Flexion Extension Side Bend R Side Bend L Rotation R Rotation L Thoracic Flexion Extension Side Bend R Side Bend L Rotation R Rotation L Palpation: _____________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Joint Play Assessment: ___________________________________________________________________ ______________________________________________________________________________________ Special Tests: __________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ HEP/Patient Education: __________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ASSESSMENT: ________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Problems/Physical Findings: ______________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ TREATMENT PLAN: __________________________________________________________________ Patient will be seen ______ x/wk for ______ wks or ______ visits for _____________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ GOALS BY Barriers to achieving treatment goals? Yes No ___________________________________________ Family/patient involved in and verbalized understanding of goals? Yes No ____________________ Patient was instructed in cervical/thoracic model as it pertains to the injury? Yes No _____________ Clinician:
