Spine Physical Examination Form
Please complete all sections of the Spine Physical Examination Form to document relevant clinical findings.
Patient Full Name
*
First Name
Last Name
Examination Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Examination
*
Location of Symptoms
*
Cervical (Neck)
Thoracic (Mid Back)
Lumbar (Low Back)
Sacral/Coccyx
Other
Pain Severity (0 = No Pain, 10 = Worst Pain)
*
0
0
1
2
3
4
5
6
7
8
9
10
10
0 is 0, 10 is 10
Range of Motion
Normal
Reduced Flexion
Reduced Extension
Reduced Lateral Bending
Reduced Rotation
Other
Neurological Findings
Normal
Weakness
Numbness
Tingling
Reflex Changes
Other
Posture Assessment
Normal
Forward Head
Rounded Shoulders
Scoliosis
Other
Special Tests
Straight Leg Raise
Slump Test
Spurling's Test
None Performed
Other
Examiner's Notes
Submit Examination
Should be Empty: