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CN Exam
Olfaction WNL
Olfaction Quality
• • •
Consensual/ Direct light testing WNL
Consensual/ Direct reflex observations
Opthalmic Exam WNL
Opthalmic Exam Quality
R Eye V/A Ratio
/
L Eye V/A Ratio
/
Confrontation Test WNL
Confrontation Test Quality
• • •
Pinwheel V1-V3 undiminished
Pinwheel V1-V3 Quality
Vibration V1-V3 undiminished
Vibration V1-V3 Quality
Muscles of Mastication WNL
Muscles Of Mastication Quality
Corneal Reflexes WNL
Corneal Reflexes Quality
• • •
Weber Test WNL
Weber Test Quality
• • •
Palate WNL
Palate Quality
• • •
Gag Reflex WNL
Gag Reflex Quality
• • •
SCM Strength
/
Upper Trapezius Strength
/
Tongue Protrusion WNL
Tongue Protrusion Quality
• • •
Extraocular Eye Exam
Extraocular Pursuits WNL
Extraocular Pursuit Quality
• • •
Extraocular Pursuits Comments
Saccade Testing WNL
Saccade Quality
• • •
Saccade Comments
Optokinetic Nystagmus Testing WNL
OKN Quality
• • •
OKN Comments
Halmagyi Testing WNL
Halmagyi Quality
• • •
Vestibulo-Ocular Reflex WNL
VOR Quality
• • •
VOR Comments
Gaze Neutral in the Dark WNL
Gaze in Dark Quality
• • •
Gaze in Dark Comments
Visual Vertical Testing WNL
Visual Vertical Quality
• • •
Visual Vertical Comments
Gaze Stability Testing
Gaze Neutral WNL
Gaze Neutral Quality
• • •
Gaze Neutral comments
Gaze Left WNL
Gaze Left Quality
• • •
Gaze Left comments
Gaze Right WNL
Gaze Right Quality
• • •
Gaze Right comments
Gaze Down WNL
Gaze Down Quality
• • •
Gaze Down comments
Gaze Up WNL
Gaze Up Quality
• • •
Gaze Up comments
Balance Testing
Eyes Closed Perturbed Surface N WNL
Sway Quality
• • •
Eyes Closed Perturbed Surface L WNL
Sway Quality
• • •
Eyes Closed Perturbed Surface R WNL
Sway Quality
• • •
Eyes Closed Perturbed Surface Flex WNL
Sway Quality
• • •
Eyes Closed Perturbed Surface Ext WNL
Sway Quality
• • •
Reflex Test
Upper/Lower Extremity MSR's WNL
Upper Extremity MSR's
C5 Left
/
C5 Right
/
C6 Left
/
C6 Right
/
C7 Left
/
C7 Right
/
UE Reflex Comments
Lower Extremity MSR's
L4 Left
/
L4 Right
/
L5 Left
/
L5 Right
/
S1 Left
/
S1 Right
/
LE Reflex Comments
Pathlogic Reflex + PM
Hoffman's Test WNL
Hoffman's Test Comments
Tromner's Test WNL
Tromner's Test Comments
Plantar Responses Flexor
Plantar Response Quality
• • •
Percussion Myotonia Testing WNL
Percussion Myotonia Quality
• • •
Muscle Testing
UE/LE Muscle Testing WNL
General Muscle Testing
Deltoid Left
/
Deltoid Right
/
Biceps Left
/
Biceps Right
/
Triceps Left
/
Triceps Right
/
Wrist Extensors Left
/
Wrist Extensors Right
/
Wrist Flexors Left
/
Wrist Flexors Right
/
Digit Extensors Left
/
Finger Extensors Right
/
Finger Flexors Left
/
Digit Flexors Right
/
Digit Abductors Left
/
Digit Abductors Right
/
Extensor Pollicis Left
/
Extensor Pollicis Right
/
Hip Flexor Left
/
Hip Flexor Right
/
Extensor Hallicus Left
/
Extensor Hallicus Right
/
General Muscle Test Comments
Shoulder/Elbow Extended
Supraspinatus Left
/
Supraspinatus Right
/
External Arm Rotation Left
/
External Arm Rotation Right
/
Internal Arm Rotation Left
/
Internal Arm Rotation Right
/
Forearm Pronation Left
/
Forearm Pronation Right
/
Forearm Supination Left
/
Forearm Supination Right
/
Brachioradialis Left
/
Brachioradialis Right
/
Shoulder/Elbow Comments
Wrist/Hand Extended
Wrist Ulnar Deviation Left
/
Wrist Ulnar Deviation Right
/
Wrist Radial Deviation Left
/
Wrist Radial Deviation Right
/
Finger Adduction Left
/
Finger Adduction Right
/
Thumb Adduction Left
/
Thumb Adduction Right
/
Thumb Opposition Left
/
Thumb Opposition Right
/
Distal Thumb Flexion Left
/
Distal Thumb Flexion Right
/
Pinky Opposition Left
/
Pinky Opposition Right
/
Wrist/Hand Comments
Hip/Knee Extended
Hip Extension Left
/
Hip Extension Right
/
Hip Adduction Left
/
Hip Adduction Right
/
Hip Abduction Left
/
Hip Abduction Right
/
Knee Flexion Left
/
Knee Flexion Right
/
Knee Extension Left
/
Knee Extension Right
/
Hip/Knee Comments
Ankle/Foot Extended
Ankle Dorsiflexion Left
/
Ankle Dorsiflexion Right
/
Ankle Inversion Left
/
Ankle Inversion Right
/
Ankle Eversion Left
/
Ankle Eversion Right
/
Ankle Plantar Flexion Left
/
Ankle Plantar Flexion Right
/
Toe Flexion Left
/
Toe Flexion Right
/
Big Toe Extension Left
/
Big Toe Extension Right
/
Big Toe Adduction Left
/
Big Toe Adduction Right
/
Ankle/Foot Comments
Cerebellar Tests
Finger-Nose WNL
Finger-Nose Quality
• • •
Finger-Nose-Finger WNL
Finger-Nose-Finger Quality
• • •
Rapid alternating movements (hand) WNL
Rapid alternating hand quality
• • •
Piano playing WNL
Piano Playing Quality
• • •
Heel to Shin WNL
Heel to Shin Quality
• • •
Gait Tests
Gait WNL
Gait Quality
• • •
Gait with Dual Task WNL
Dual Task Gait Quality
• • •
Heel to Toe Walk WNL
Heel to Toe Walk Quality
• • •

Initial Exam Medical Form

Chiropractor

Draft 4

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Published: Jan. 20, 2016, 9:25 p.m.
Doctor: Dr. History Physical
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