neck pain

onset

hours days weeks months years sudden gradual

new?

new issue previously known issue

intensity

mild mild-moderate moderate moderate-severe severe

frequency

single episode constant intermittent daily few times a week few times a month

duration

few minutes less than an hour few hours most of the day few days

status

improving unchanged resolved gradually worsening significant worsening

context

trauma/fall yes no repetitive movement yes no

location

midline left sided right sided c-spine muscular

radiation

none entire spine left shoulder right shoulder left hand right hand

quality

debilitating dull pressure superficial sharp throbbing stabbing

timing

daytime upon awakening night time

aggravated by

nothing flexion extension all movements rotating left rotating right

relieved by

nothing flexion extension movements lying down stretching OTC meds prescription meds massage heat ice

red flags

all reviewed, negative

inspection

normal

palpation

normal

ROM

radicular testing

right

normal motor

normal sensation or abnormal sensation at:

lateral arm/deltoid (C5)

lateral forearm/hand (C6)

middle finger (C7)

medial forearm/hand (C8)

medial upper arm (T1)

normal reflexes or abnormal reflexes:

biceps (C5)

brachioradialis (C6)

triceps (C7)

Hoffman

inverted radial

left

normal motor

normal sensation or abnormal sensation at:

lateral arm/deltoid (C5)

lateral forearm/hand (C6)

middle finger (C7)

medial forearm/hand (C8)

medial upper arm (T1)

normal reflexes or abnormal reflexes:

biceps (C5)

brachioradialis (C6)

triceps (C7)

Hoffman

inverted radial

other

Assessment:

mechanical neck pain non mechanical neck pain

acuity

acute chronic acute on chronic

red flags

no red flags

radicular symptoms

positive negative

imaging

no indication X-Ray

details

Plan:

medication

tylenol topical NSAIDs PO NSAIDs opioids

physiotherapy

self referral MFP physio

-> private coverage?

yes no

other therapy

massage therapy

off work

yes (1-2 weeks) no

follow-up

2-4 weeks PRN only

RTC

instructions given

other

NECK PAIN

S/

O/

A/

P/