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. www.prohealthsys.com 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: