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. Author manuscript; available in PMC: 2014 Nov 1.
Published in final edited form as: PM R. 2013 Jun 28;5(11):931–938. doi: 10.1016/j.pmrj.2013.06.006

Table 2.

Physical Exam Data Form

  • 1

    Subject Identification Number: –––––––––––––––

  • 3

    Do you have neck pain: Yes No Side: ––––––––

  • 4

    Which side is the pain? Left Right Both

  • 5

    Is it local or widespread pain? –––––––––––

  • 6

    How long have you experienced neck pain? ––––––––

  • 7

    How long has this particular episode lasted? ––––––––

  • 8

    Does the pain occur intermittently or for extended periods of time? ––––––––

  • 9

    Does it occur for most of the day? Yes No

  • 10

    Is the pain worse at a particular time of day (morning, evening, night?) ––––––––

  • 11

    What alleviates pain?

    1. Exercise (stretching etc)

    2. Therapeutic modalities (heat, ultrasound, massage…etc)

    3. Medication (anti-inflammatory, analgesic,, muscle relaxer…etc)

  • 12

    What aggravates it? –––––––––––––––

  • 13

    Describe the nature of the pain: sharp, dull, shooting, stabbing, tight, aching…etc

  • 14

    Do you experience any numbness or tingling? Yes No Location: ––––––––

    On the picture below, please mark the areas where you feel pain.

    14