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  • Neck Pain MDS - 24 Jul 07

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    amj20008
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    This document appears to be a form used to collect patient information and document physical therapy treatment for cervical spine issues. It includes sections to record patient demographics, history, symptoms, physical exam findings, classification of the issue, pain levels, and disability scores. Treatment is documented with checkboxes to indicate which interventions were used at each visit, such as various exercises, modalities, mobilization and manual therapy techniques. Spaces are also included to record range of motion, dates of visits, and duration of care.

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    Neck Pain MDS_24 Jul 07

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    This document appears to be a form used to collect patient information and document physical therapy treatment for cervical spine issues. It includes sections to record patient demographics, history, symptoms, physical exam findings, classification of the issue, pain levels, and disability scores. Treatment is documented with checkboxes to indicate which interventions were used at each visit, such as various exercises, modalities, mobilization and manual therapy techniques. Spaces are also included to record range of motion, dates of visits, and duration of care.

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    52 views1 page

    Neck Pain MDS - 24 Jul 07

    Uploaded by

    amj20008
    This document appears to be a form used to collect patient information and document physical therapy treatment for cervical spine issues. It includes sections to record patient demographics, history, symptoms, physical exam findings, classification of the issue, pain levels, and disability scores. Treatment is documented with checkboxes to indicate which interventions were used at each visit, such as various exercises, modalities, mobilization and manual therapy techniques. Spaces are also included to record range of motion, dates of visits, and duration of care.

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    of 1

    Cervical Form

    Examined by:  Licensed PT  Student PT  Both Treated by:  Licensed PT  Student PT  Both
    Demographics & History (Initial Only)
    Patient ID: Total duration of symptoms (yrs): Height: ____ ft ____ in Wt (lb):______
    Date (Initial): Gender:  Male  Female Age:

    Location (check all that apply): Other signs/symptoms/conditions (check all applicable):
     Neck  N/A  Thoracic Spine  Hypertension: BP _____ / ______
     Thorax  Upper Extremity(ies)  Hip(s)  Diabetes
     Arm above elbow (Bilat Uni)  Knee(s)  Foot/Feet  Pulmonary Conditions/Disease
     Arm below elbow (Bilat Uni)  Back Pain  Shoulder Pain  Obesity
     Head ( Bilat  Unilat)  Headache  Dizziness/Light Headedness  Depression
     Hemifacial Sxs ** Smoking (circle): Current smoker / Smoked in past / Never Smoked
    Duration current episode Medications For:  Cardiac  Cholesterol  Vascular  Depression  Diabetes
    (days):__________  Shoulder Pain  Other musculoskeletal pain  Other_______________
    FABQ (modified for neck) Post surgical?  Yes  No Previous episodes of neck pain:  0  1-2  3-5  >5
    PA______ WK________ Sought medical care for this same Frequency increasing?  Yes  No
    episode in the past?  Yes  No Is this injury due to whiplash?  Yes  No

    PHYSICAL EXAM: (Initial Only)


    Upper limb tension:  +  — Posture: Cervical ROM: Centralization:
    Spurling’s:  +  -  Not Indicated  Flat upper t-spine Flex:____ Ext:____  Centralizes
    Distraction:  +  -  Not Indicated  Increased kyphosis SBR:____ SBL:____  Cannot centralize
    Cervical rot<60o:  +  - upper t-spine RR:____ LR:____  Not applicable
     Normal
    Deep neck flexor endurance (secs): _______ Dermatomes (C5-T1) Myotomes (C5-T1) Reflexes:
     Normal  Abnormal  Normal  Abnormal C5:Nl Dec Inc
    Cervical rotation lateral flexion:  +  -  Not Indicated  Not Indicated C6:Nl Dec Inc
    If abnormal, which If abnormal, which C7:Nl Dec Inc
    dermatome(s)(circle): myotome(s): (circle)  Not Indicated
    C5 C6 C7 C8 T1 C5 C6 C7 C8 T1

    Classification NPRS (0-10) NDI


    Interventions
    (circle one) Avg past 24 hrs
    1 2 3 4
    Initial / Wk 1 Mobilization Centralization HA
    Pain Control Exercise & Endurance
    2 Wk Mobilization Centralization HA
    Pain Control Exercise & Endurance
    3 Wk Mobilization Centralization HA
    Pain Control Exercise & Endurance
    4 Wk Mobilization Centralization HA
    Pain Control Exercise & Endurance
    5 Wk Mobilization Centralization HA
    A. Patient Education/Instruction I. Aerobic
    Pain Exercise
    Control Exercise & Endurance Q. Neck Flexor Strengthening
    B.
    6 Wk Mobility Exercises-Cervical J. General Conditioning
    Mobilization Exercises
    Centralization HA R. NMES (Strengthening)
    C. Mobility - Thoracic Spine/Rib Cage K. Muscle
    Pain Flexibility
    Control Exercise- Cervical Muscles
    & Endurance S. NMES (Pain Control)
    D.
    D/C Thrust Manipulation - Cervical L. Muscle Flexibility
    Mobilization - Scapular/Chest
    Centralization HA T. Soft Tissue Massage
    E. Thrust Manipulation - Tx / Rib Cage M. ColdControl
    Pain Modalities
    Exercise & Endurance U. Myofascial Release
    F. Non-thrust maniplation/mobilization-Cx N. Thermal Modalities V. Craniosacral Therapy
    G. Non-thrust manip/mobilization-Tx/Rib O. Traction—Mechanical/Manual (circle) W. Other_________________
    H. Repeated Retraction Exs (McKenzie) P. Behavioral Exercise Approach X. Other__________________

    Date of Last Visit: ______/_______/_______ Duration of Care To Date (days):____________


    Is the last visit the discharge visit: Yes / No Number of Visits To Date: __________

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