Torticollis Assessment Form
Please complete this form to assist in the assessment of torticollis symptoms and history.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
When did the symptoms begin?
*
Please Select
Less than 1 week ago
1–4 weeks ago
1–3 months ago
More than 3 months ago
Unsure
How severe is the neck pain or discomfort?
*
1
2
3
4
5
6
7
8
9
10
Neck Movement Limitations
*
Rows
No limitation
Mild limitation
Moderate limitation
Severe limitation
Rotation (turning head left/right)
1
2
3
4
Lateral flexion (tilting ear to shoulder)
5
6
7
8
Flexion (chin to chest)
9
10
11
12
Extension (looking up)
13
14
15
16
Observed posture or head tilt
*
No abnormal tilt
Tilted to left
Tilted to right
Chin rotated to left
Chin rotated to right
Other
Associated symptoms (select all that apply)
Headache
Shoulder pain
Muscle spasms
Numbness/tingling
Visual changes
Other
Possible triggering event
Recent injury or trauma
Recent infection or illness
Sudden movement
No obvious trigger
Other
Have you received any prior treatment for this condition?
No prior treatment
Physical therapy
Medication
Other
Additional notes or comments
Submit Assessment
Should be Empty: