Patient Assessment Evaluation Form
CRANIAL NERVE SCREEN Clear Abn.
CN I (olfactory) cn_i_olfactory == 1 ? 'checked' : '' }}> cn_i_olfactory == 0 ? 'checked' : '' }}>
CN II (visual fields,pupiIlary reflex) cn_ii_visual_fields_pupillary_reflex == 1 ? 'checked' : '' }}> cn_ii_visual_fields_pupillary_reflex == 0 ? 'checked' : '' }}>
CN III(H Pattern) cn_iii_h_pattern == 1 ? 'checked' : '' }}> cn_iii_h_pattern == 0 ? 'checked' : '' }}>
CN IV(SO - lat/inf) cn_iv_so_lat_inf == 1 ? 'checked' : '' }}> cn_iv_so_lat_inf == 0 ? 'checked' : '' }}>
CN V(Sensory/mastication mm) cn_v_sensory_mastication_mm == 1 ? 'checked' : '' }}> cn_v_sensory_mastication_mm == 0 ? 'checked' : '' }}>
CN VI(LR-lat) cn_vi_lr_lat == 1 ? 'checked' : '' }}> cn_vi_lr_lat == 0 ? 'checked' : '' }}>
CN VII(facial expression mm) cn_vii_facial_expression_mm == 1 ? 'checked' : '' }}> cn_vii_facial_expression_mm == 0 ? 'checked' : '' }}>
CNVIII (nystag, whisper) cn_viii_nystag_whisper == 1 ? 'checked' : '' }}> cn_viii_nystag_whisper == 0 ? 'checked' : '' }}>
CN IX(taste/posteriortongue) cn_ix_taste_posterior_tongue == 1 ? 'checked' : '' }}> cn_ix_taste_posterior_tongue == 0 ? 'checked' : '' }}>
CN X(uvula, swallow, vocal cords) cn_x_uvula_swallow_vocal_cords == 1 ? 'checked' : '' }}> cn_x_uvula_swallow_vocal_cords == 0 ? 'checked' : '' }}>
CN IX(Trap,SCM) cn_xi_trap_scm == 1 ? 'checked' : '' }}> cn_xi_trap_scm == 0 ? 'checked' : '' }}>
CN IX(tongue mm, articulation) cn_xii_tongue_mm_articulation == 1 ? 'checked' : '' }}> cn_xii_tongue_mm_articulation == 0 ? 'checked' : '' }}>
GROSS NEUROVASCULAR
Cerebellar Signs? {{ $data->cerebellar_signs == 1 ? 'Yes' : 'No' }}
{{ $data->cerebellar_signs_if_yes }}
UMN Signs? {{ $data->umn_signs == 1 ? 'Yes' : 'No' }}
{{ $data->umn_signs_if_yes }}
Sensory Changes? {{ $data->sensory_changes == 1 ? 'Yes' : 'No' }}
{{ $data->sensory_changes_if_yes }}
Myotome Weakness? {{ $data->myotome_weakness == 1 ? 'Yes' : 'No' }}
{{ $data->myotome_weakness_if_yes }}
DTRs {{ $data->dtrs }}
Vast {{ $data->vast == 1 ? 'Neg' : 'Pos' }}
5D's, 3N's(list) {{ $data->{'5ds_3ns_list'} }}

Vestibular & Oculomotor Screen
Gaze Fixation {{ $data->gaze_fixation_symptoms }}
NPC
{{ $data->npc_2 }}
{{ $data->npc_3 }}
{{ $data->npc_4 }}
{{ $data->npc_symptoms }}
Accommodation
Pursuits {{ $data->pursuits_symptoms }}
Saccades {{ $data->saccades_symptoms }}
VOR (180 bpm) {{ $data->vor_symptoms }}
VMS (50 bpm) {{ $data->vms_symptoms }}
Clinical Evaluation P2 - Special Testing (If Indicated)
Head Thrust Test
Dynamic Visual Acuity {{ $data->special_testing_dynamic_visual_acuity_text }}
Dix Hallpike {{ $data->special_testing_dix_hallpike_text }}
Lateral Pos/Head Roll {{ $data->special_testing_lateral_pos_head_roll_text }}
Visual Fields (confrontation)
{{ $data->special_testing_visual_fields_confrontation_text }}
Other

Balance And Gait
Normal Gait
Tandem Gait (fwd, bkwd)
Eyes open, 5 steps*
Tandem Gait (fwd, bkwd)
Eyes closed, 5 steps*
Balance: Feet together (Firm)
Eyes closed (20s)*
Balance: Semi Tandem (Firm)
Eyes closed (20s)*
Balance: Feet Together (Foam)
Eyes closed (20s)*
Others
Clinical Evaluation P3 - Cervical/Ortho Screen
Upper Cervical Ligs
Range Of Motions
Flexion(5d)
Extension (60d)
Right Lateral Flexion (40-45d)
Left Lateral Flexion (40-45d)
Right Rotation (80d)
Left Rotation (80d)

cervical_ortho_screen_flexion_5d == 'Normal' ? 'checked' : '' }}> Normal cervical_ortho_screen_flexion_5d == 'Reduced' ? 'checked' : '' }}> Reduced
cervical_ortho_screen_extension_60d == 'Normal' ? 'checked' : '' }}> Normal cervical_ortho_screen_extension_60d == 'Reduced' ? 'checked' : '' }}> Reduced
cervical_ortho_screen_right_lateral_flexion_40_45d == 'Normal' ? 'checked' : '' }}> Normal cervical_ortho_screen_right_lateral_flexion_40_45d == 'Reduced' ? 'checked' : '' }}> Reduced
cervical_ortho_screen_left_lateral_flexion_40_45d == 'Normal' ? 'checked' : '' }}> Normal cervical_ortho_screen_left_lateral_flexion_40_45d == 'Reduced' ? 'checked' : '' }}> Reduced
cervical_ortho_screen_right_rotation_80d == 'Normal' ? 'checked' : '' }}> Normal cervical_ortho_screen_right_rotation_80d == 'Reduced' ? 'checked' : '' }}> Reduced
cervical_ortho_screen_left_rotation_80d == 'Normal' ? 'checked' : '' }}> Normal cervical_ortho_screen_left_rotation_80d == 'Reduced' ? 'checked' : '' }}> Reduced
Joint Tenderness
Upper Cervical (C1-3)
Lower Cervical (C4-7)

cervical_ortho_screen_upper_cervical_c1_3 == 'Normal' ? 'checked' : '' }}> Normal cervical_ortho_screen_upper_cervical_c1_3 == 'Pain/Restriction' ? 'checked' : '' }}> Pain/Restriction
cervical_ortho_screen_lower_cervical_c4_7 == 'Normal' ? 'checked' : '' }}> Normal cervical_ortho_screen_lower_cervical_c4_7 == 'Pain/Restriction' ? 'checked' : '' }}> Pain/Restriction
Myofascial Tone/Tenderness
Suboccipital
Other

cervical_ortho_screen_suboccipital == 'Normal' ? 'checked' : '' }}> Normal cervical_ortho_screen_suboccipital == 'Pain/Restriction' ? 'checked' : '' }}> Pain/Restriction
cervical_ortho_screen_other == 'Normal' ? 'checked' : '' }}> Normal cervical_ortho_screen_other == 'Pain/Restriction' ? 'checked' : '' }}> Pain/Restriction
Special Testing (eg. C-Flex/Rot;
Comp/Spurl/DNF/N.Torsion/Rotary stool):
Clin Impression {{ $data->clin_impression }}
Trajectories {{ $data->trajectories }}
Referrals {{ $data->referrals }}
POM {{ $data->pom }}
Tests to Perform {{ $data->tests_to_perform }}
Rehab to Initiate {{ $data->rehab_to_initiate }}
If Others {{ $data->rehab_to_initiate_if_others }}
Patient Aware Care to be shared w/ Kin and Consents? {{ $data->patient_aware_care_to_be_shared_w_kin_and_consents == 1 ? 'Yes' : 'No' }}
{{ $data->patient_aware_care_to_be_shared_w_kin_and_consents_if_yes }}
Name {{ $data->name }}
Signature {{ $data->patient_signature }}
Date {{ $data->patient_date }}
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