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Treatment Assessment

To Estimate The Parameters of Needed Chiropractic Care

Bold Numbers Indicate Extent of The Problem

When you choose Dr. Eyre, you will discuss the reasons for scheduling an appointment for chiropractic care. During your first appointment, Dr. Eyre will complete the following assessment form to develop a plan of action tailored to your enhanced wellness and treatment. If you reside in Santa Rosa, CA, contact Dr. Eyre today to schedule an appointment.

I. Degree of Pain

A. Severity of Pain

(1) 1. Minimal - An annoyance, no restriction with activities
(2) 2. Slight - Some handicap in the performance of the offending activity
(4) 3. Moderate - Marked handicap in the performance of the offending activity
(8) 4. Severe - The pain cannot be tolerated; the offending activity cannot be performed.

B. Frequency of Pain

(1) 1. Occasional - Pain occurs from 0% to 25% of the time
(2) 2. Intermittent - Pain occurs from 26% to 50% of the time
(4) 3. Frequent - Pain occurs from 51% to 75% of the time
(8) 4. Constant - Pain occurs from 76% to 100% of the time

C. Duration of Pain

(1) 1. 1 to 3 days
(2) 2. 3 to 7 days
(3) 3. 2 to 4 weeks
(4) 4. 2 to 3 months
(6) 5. 4 to 6 months
(8) 6. 7 to 12 months
(12) 7. 1 to 2 years
(16) 8. 2 or more years

D. Radiation of Symptoms into the extremities

(4-16) 1. Pain in arm and/or legs
(4-16) 2. Numbness (pins or needles) in arms and/or legs
3. Muscle weakness
(4-8) a. Loss of grip strength-major hand should be 10-20% stronger than minor hand
(4-8) b. Difficulty in performing the heel and/or toe walk

II. Type of Injury

A. Minor twist/bend/stretch/lift
(3-4) B. Moderate twist/bend/stretch/lift
(5-8) C. Severe twist/bend/stretch/lift
(1-2) D. Minor slip and fall
(3-4) E. Moderate slip and fall
(5-8) F. Severe slip and fall
(4-8) G. A fall from height
(4-8) H. Minor auto accident
(9-20) I. Moderate auto accident
(4-20) J. Repetitive motion injury

III. History of Previous Injuries

(1-8) A. Number of previous injuries ______
(1-8) B. Severity of previous injuries (minimal, slight, moderate or severe)

IV. Age

(0) A. Under 20 years of age
(1) B. 20 to 29 years of age
(2) C. 30 to 39 years of age
(3) D. 40 to 49 years of age
(4) E. 50 to 59 years of age
(6) F. 60 to 69 years of age
(8) G. 70 to 79 years of age
(10) H. 80 years of age or older

V. Weight

(2) A. More than 20% above normal for height and build
(4) B. More than 30% above normal for height and build
(8) C. More than 40% above normal for height and build
(12) D. More than 50% above normal for height and build

VI. Exercise And/Or Activity Level

(-8) A. Exercises vigorously for 20-30 minutes 3/week (not including warmup/cool down)
(-4) B. Very active at work (manual labor, using good body mechanics)
(0-2) C. Somewhat active at work or during free time
(3-8) D. Minimal exertion at work or during free time

VII. Concussion

(0-6) A. No loss of consciousness
(4-12) B. With mental confusion (difficulty processing information)
(6-12) C. With loss of memory
(6-12) D. With loss of consciousness

VIII. Altered Range of Motion (with/without Pain)

(2-8) A. Cervical spine (neck area)
(2-8) B. Lumbar spine (lower back area)

IX. Positive Orthopedic and/or Neurologic Examination Findings

(1-12) Rating depends on the number of positive tests, and importance of those tests

X. Muscle Spasms

(1-4) A. Minimal to Slight
(5-7) B. Moderate
(8-16) C. Severe

XI. Excessive Tenderness (pain with pressure/touch; inflammation)

(2-3) A. One area (cervical, thoracic or lumbo-sacral)
(4-5) B. Two areas (cervical/thoracic; cervical/lumbo-sacral; thoracic/lumbo-sacral)
(6-8) C. Three areas (cervical, thoracic and lumbo-sacral)

XII. Posture Analysis

A. Scoliosis (lateral deviation of the spine)
(6-12) 1. Congenital
2. Acquired
(2) a. Resulting from muscle spasm (causing antalgic posture), usually temporary
(1-4) b. Resulting from leg length deficiency, from injury or unequal growth rate
(4) 3. Congenital or Acquired with rotation
(4-8) B. Kyphosis - Increased curve of the thoracic spine (upper back)
C. Lordosis
(1-2) 1. Increased curve of the cervical spine (lower neck)
(1-4) 2. Increased curve of the lumbar spine (lower back)

(1-4) D. Head translation (holding the head somewhat forward of the truck)

(0-12) E. Foot Pronation (flat feet) - may be improved/eliminated with orthotics
F. Knee Involvement
(1-4) 1. Genu varus (knock knees)
(1-4) 2. Genu valgus (bowed legs)

XIII. X-Ray/MRI Findings

A. Altered curves or angles
(4-8) 1. Decreased or increased cervical curve
(1-4) 2. Decreased lumbar curve or increased lumbo-sacral angle
B. Apparent disc involvement
(4-12) 1. Reduced disc space
(4-20) 2. Disc bulging/protrusion (seen on MRI)
C. Bony Degeneration
1. Osteoarthritis (spurring) - the more areas involved, the more serious.
(1-2) a. minimal
(3-7) b. slight
(8-11) c. moderate
(12-16) d. severe
(20) 2. Ankylosis - natural fusion of a joint (the final progression of osteoarthritis)
D. Scoliosis/Kyphosis confirmed
(1-20) E. Congenital abnormalities (birth defects)
F. Acquired abnormalities
(2-8) 1. Spondylolisthesis (fracture or failure of fusion of the pars interarticularis)
(4-12) 2. Wedged vertebra (from a healed compression fracture)
(4-20) G. Spinal surgery (fusion, disc surgery, laminectomy, metal plates/screws)
H. Fracture of structurally significant bones

(4-12) 1. Recent fracture (delays care of soft tissue injury until fracture is healed, 6-8 weeks)

(0-8) 2. Old healed fracture
(4-12) I. Dislocations/separations

Total Points Scored __________

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1870 Judson Lane | Santa Rosa, CA 95401

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3:00 pm-6:00 pm




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3:00 pm-6:00 pm




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3:00 pm-6:00 pm


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