Align Co. — NeuroPath Initial Examination
CVC Spine & Sport · Peripheral Nerve Wellness Program
Patient
Complaints
Thermal
Feet
Hands
Functional
Report
Patient Information
New Patient — Initial Intake
Complete all fields before beginning examination
🔒 Texas Scope Compliance: We document complaints and wellness findings, not diagnoses. Use approved language: "peripheral nerve wellness evaluation," "sensation assessment," "numbness/tingling support program." Never document: "neuropathy diagnosis," "nerve damage," or "we treat neuropathy."
Chief Complaints & History
Symptom Profile
Check all that apply
Type of Sensation Changes
Numbness
Tingling / pins & needles
Burning discomfort
Sharp / shooting sensation
Cold feet / cold hands
Hypersensitivity to touch
Muscle weakness
Balance difficulty
Difficulty walking / unsteady gait
Sleep disruption from discomfort
GI / digestive concerns
Swelling in lower extremities
Affected Regions
Left Foot
Right Foot
Both Feet
Left Hand
Right Hand
Both Hands
Lower Legs
Forearms
Patient-Reported Contributing Factors
Elevated blood sugar (patient-reported)
Prior chemotherapy
Alcohol use history
Nutritional concerns
Prior back / spine history
Autoimmune condition (patient-reported)
Thyroid disorder (patient-reported)
Unknown / idiopathic
Thermal Imaging Findings
🌡️ Document thermal camera findings using the color zone scale: Green = normal blood flow | Yellow = mildly reduced | Red = significantly reduced / poor perfusion
Left Foot
Blood Flow / Perfusion Zone
🟢 Normal
🟡 Mildly Reduced
🔴 Significantly Reduced
Temp. Differential (vs contralateral / proximal)
Zones Affected
Toes
Ball of foot
Arch
Heel
Dorsum
Ankle
Right Foot
Blood Flow / Perfusion Zone
🟢 Normal
🟡 Mildly Reduced
🔴 Significantly Reduced
Temp. Differential
Zones Affected
Toes
Ball of foot
Arch
Heel
Dorsum
Ankle
Left Hand
Blood Flow / Perfusion Zone
🟢 Normal
🟡 Mildly Reduced
🔴 Significantly Reduced
Temp. Differential
Zones Affected
Fingertips
Fingers
Palm
Dorsum hand
Wrist
Forearm
Right Hand
Blood Flow / Perfusion Zone
🟢 Normal
🟡 Mildly Reduced
🔴 Significantly Reduced
Temp. Differential
Zones Affected
Fingertips
Fingers
Palm
Dorsum hand
Wrist
Forearm
Overall Thermal Impression
Clinician's summary of all thermal findings
Sensory Evaluation — Feet
Score 0–10 (10 = full sensation) or –5 (allodynia/hypersensitivity). ReBuilder reaction time is recorded at the end of ALL sensory testing.
Left Foot 7 Tests
| Test | Score (0–10 / –5) | Value |
|---|---|---|
| Total /70 → % Preserved → % Sensory Loss | — | |
Right Foot 7 Tests
| Test | Score (0–10 / –5) | Value |
|---|---|---|
| Total /70 → % Preserved → % Sensory Loss | — | |
Sensory Evaluation — Hands
Left Hand 7 Tests
| Test | Score (0–10 / –5) | Value |
|---|---|---|
| Total /70 → % Preserved → % Sensory Loss | — | |
Right Hand 7 Tests
| Test | Score (0–10 / –5) | Value |
|---|---|---|
| Total /70 → % Preserved → % Sensory Loss | — | |
ReBuilder Reaction Time — All Limbs
Performed after all manual sensory tests are complete. Scale 1–8 (1 = fastest / normal response) or DNF (did not feel).
Left Foot
Right Foot
Left Hand
Right Hand
Functional Testing
Balance & Postural Assessment
Sway, stance, and gait findings
Romberg (eyes open)
Normal
Mild Sway
Sig. Sway
Unable
Romberg (eyes closed)
Normal
Mild Sway
Sig. Sway
Unable
Tandem Walk
Normal
Mild Impairment
Moderate
Unable
Single Leg Stance
≥10 sec
5–9 sec
<5 sec
Unable
Gait Pattern
Normal
Antalgic
Ataxic
Steppage
Fall History
No Falls
Near-Falls
1–2 Falls/yr
Frequent Falls
Orthopedic Differential Testing
Differentiating radicular (structural) vs. peripheral nerve causes. Results inform care direction — NOT used to diagnose.
⚠️ Documentation note: Record findings as positive/negative/equivocal observations. Do not document as a spinal diagnosis. If radicular pattern is strongly suspected, note referral recommendation.
SLR — Straight Leg Raise
L4–S1 nerve root tension. Positive if symptom reproduction <70°.
Left
Negative
Positive
Equivocal
N/T
Right
Negative
Positive
Equivocal
N/T
Slump Test
Sciatic nerve / dural tension. Differentiates nerve root from peripheral.
Negative
Positive
Equivocal
N/T
Kemp's / Quadrant Test
Lumbar facet / foraminal compression. Positive = radiating pain or reproduced sx.
Left
Negative
Positive
Equivocal
N/T
Right
Negative
Positive
Equivocal
N/T
Differential Impression
Pattern consistent with peripheral origin
Radicular component cannot be ruled out
Mixed picture — peripheral + structural
Spinal referral recommended
Vascular component suspected
Metabolic/systemic component suspected
Report of Findings
Initial Exam — Patient
Date — Clinician
—
L Foot Loss
—
R Foot Loss
—
L Hand Loss
—
R Hand Loss
—
Thermal
—
Ortho Diff.
—
Balance
—
Overall
Complete all steps and click "Generate Report" below.
Step 1 of 7 — Initial Exam