Cervicothoracic Regional Exam
Patient:____________________________________ date: ______
Insurance: ______________________________________ (dd/mm/yr)
______________________________________________________________________________________
Date of birth: ____________________________________ M/F
Check normal, circle & describe abnormal
Chief complaint & signicant history:
_______________________________________________________________________________________________________________________
Vital Signs: Height: __________, Weight: __________, Blood Pressure: L ________/________, R ________/________, Resp: __________/min, VBI: L ________ R ________
Observation:: WNL
Development: good, fair, poor
Posture: _________________________
Skin (bruising, scars): _______________
Antalgia: _________________________
Asymmetry: _______________________
Observation
Thoracic
Cervical
Head tilt
Palpation
Lymph nodes
Temporalis
Masseter
TMJ
SCM
Head carriage (ant. / post.)
Levator scapulae
Lordosis (hyper / hypo)
Trapezius/rhomboids
High shoulder
Suboccipitals
Scoliosis
Posterior c-spine muscles
Kyphosis (hyper / hypo)
Trachea mobility
Adams sign
Thyroid gland
___________________________________
___________________________________
___________________________________________
___________________________________________
___________________________________
Clavicle / thoracic outlet
Rotator cuff
Neurologic:: WNL
Sensation WNL
ROM & Joint Play:: WNL
Reexes (0-5) WNL
Biceps (C5)(musculocut.)
Extension (60)
Brachioradialis(C6)(radial)
Lateral exion (45)
Triceps (C7)(radial)
Motor (0-5) WNL
L
Cervical extension (C2, C3, XI)
Extension (50)
Cervical lat. exion (C3)
Abduction (180)
Cervical rotation (C1-4, XI)
Internal rotation (90)
External rotation (80)
Scapulocostal rhythm
TMJ
Depression/elevation
Lateral deviation
___________________________________
___________________________________
___________________________________________________
___________________________________________________
___________________________________
___________________________________
___________________________________________________________________
Cervical exion (C1-C2)
Flexion (180)
Adduction (30)
C0
C1
Max. compression
C2
Cervical distraction
C3
Soto Hall
C4
Julls test
C5
Brachial stretch
C6
Shoulder depression
C7
T1
TOS
L
R
T2
Edens
T3
Wrights
T4
Adsons
T5
Roos
T6
_____________________________________________
_____________________________________________
________________________________________________
_______________________________________________
Cervical compression
Vibration
Rotation (80)
Screening
Valsalva
Passive
R
Sharp/dull
Active
R
Orthopedic:: WNL
Light touch
Flexion (50)
Shoulder
Skin (masses, temp)
Scalenes
Head rotation
Cervical spine
Mark on drawing pain (circle), spasm (s), edema (e), brotic (f),
MFTP (x), ache (a), burning (b), tingling (t)
Palpation:: WNL
Trapezius (CN XI)(accessory)
Deltoid (C5)(axillary)
Biceps (C6)(musculocut.)
Triceps (C7, C8)(radial)
Wrist extensors (C6)(radial)
Wrist exors (C7)(med./ulnar)
Interossei (C8, T1)(ulnar)
Cranial nerves WNL
I (smell)
VII (facial expres)
II (light, vision)
VIII (Weber, Rinne)
III, IV, VI (gaze)
IX, X (ahhh)
V (bite, sensation)
XI (trap/SCM)
V, VII (corneal ref.)
XII (tongue)
________________________________
This form is a comprehensive checklist of examination procedures. Each item should be utilized as a diagnostic option based on the patients presenting
symptoms and the clinical discretion of the examiner. Every procedure does not have to be performed on every patient. Some procedures may be
contraindicated in certain situations. Patient information contained within this form is considered strictly condential. Reproduction is permitted for personal use,
not for resale or redistribution. [Link] 2005 by Professional Health Systems Inc. All rights reserved. Dedicated to Clinical Excellence.
Additional procedures:: WNL
Abdominal exam: _____________________________
Auscultation (heart, lungs): _____________________
Ophthalmoscopic exam: _______________________
Otoscopic exam:
exam: _____________________________
Other: _____________________________________
DDx: _____________________________________
_____________________________________________
______________________________________________
Signature:
Date:
