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VITALS
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Blood Pressure
/
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Height
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Weight
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Blood Oxygen Levels
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GENERAL REVIEW OF SYSTEMS
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Eyes
• • •
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Constitutional
• • •
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Ears, nose, mouth, and throat
• • •
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Cardiovascular
• • •
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Respiratory
• • •
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Gastrointestinal
• • •
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Genitourinary
• • •
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Integumentary
• • •
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Neurological
• • •
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Musculoskeletal
• • •
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Hematologic/lymphatic
• • •
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Psychiatric
• • •
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GENERAL EXAM
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General
• • •
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Psych
• • •
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Pain behavior?
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Eyes
• • •
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Ears, nose, mouth, and throat
• • •
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Neck
• • •
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Respiratory
• • •
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Cardiovascular
• • •
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GI/Abdomen
• • •
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GU
• • •
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Skin
• • •
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Cervical Testing
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Cervical MSK/Neuro Exam Performed?
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Pain Rating
/
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ROM
• • •
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Facet loading
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Skin
• • •
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Paravertebral palpation
• • •
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Spurling
• • •
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Occipital
• • •
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Additional Notes
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Lumbar Testing
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Lumbar MSK/Neuro Exam Performed?
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Pain Rating
/
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ROM
• • •
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Facet loading
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Skin
• • •
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Paravertebral palpation
• • •
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SLR
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LE Strength
• • •
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Heel Walk
• • •
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Toes Walk
• • •
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LE Sensory Exam
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Additional Notes
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Knee Reflexes (L / R)
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Ankle Reflexes (L / R)
/
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Calf Tenderness/Asymmetry/Mass/Edema
• • •
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Hip Exams
• • •
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Shoulder Testing
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Shoulder Exam Performed?
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Shoulder ROM
• • •
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Pain Rating
/
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Tenderness?
• • •
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Tests Peformed
• • •
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Ability to Raise Shoulders
• • •
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Additional Notes
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