Dr. Wasif Rizwan Malik

MBBS · FCPS (Neurosurgery) · Consultant Neurosurgeon & Brain–Spine Surgeon

Faraz Hospital, Dubai Mahal Chowk, Bahawalpur  |  0622885604  |  wasif.malik@gmail.com
Senior Registrar Neurosurgery, Bahawal Victoria Hospital (BVH), Bahawalpur

Spine ProformaPatient Evaluation Form

Date: _____ / _____ / _______
Ref No: ________________
Referring Physician: _____________

📋Chief Complaint & History of Presenting Illness
🔴Pain Characterization
At Rest:
0
1
2
3
4
5
6
7
8
9
10
Active:
0
1
2
3
4
5
6
7
8
9
10
⚡Neurological Symptoms
m
🚨 Cauda Equina / Myelopathy Flags
📂Past Medical History / Medications / Social
🩺Physical Examination
General / Posture / Gait
Flexion
Extension
L Rotation
R Rotation
Flexion
Extension
L Lateral
R Lateral
Motor Power (MRC Grade 0–5)
MovementLevelRightLeft
Shoulder AbductionC5
Elbow FlexionC5–C6
Wrist ExtensionC6
Finger ExtensionC7
Intrinsics (grip)C8–T1
Hip FlexionL1–L2
Knee ExtensionL3–L4
Ankle DorsiflexionL4–L5
Great Toe ExtensionL5
Plantar FlexionS1
Deep Tendon Reflexes (0 = Absent, + = Reduced, ++ = Normal, +++ = Hyperreflexic)
ReflexLevelRightLeft
BicepsC5–C6
TricepsC7
BrachioradialisC6
Knee JerkL3–L4
Ankle JerkS1
Plantar ResponseUMN
Abdominal ReflexT8–12
Anal WinkS3–S4
Sensory Examination
Special Clinical Tests
LUMBAR
°
°
CERVICAL
MYELOPATHY
SACROILIAC / HIP
🔬Investigations
Imaging
Electrophysiology / Labs
Radiological Summary
✅Working Diagnosis & Management Plan
Primary Diagnosis
ICD Code
Management Plan
Protocol By: Dr. Wasif Rizwan Malik | MBBS, FCPS Neurosurgery | Faraz Hospital, BVH Bahawalpur SPINE EVALUATION PROFORMA  |  Signature: ____________________