Follow the steps to fill out the form online.

1. Press the ‘Get Form’ button to access the form and open it in your preferred browser or PDF editor.
2. Begin by entering the date in the specified field at the top of the form.
3. Provide the patient's name in the designated area following the date entry.
4. Input the claim number in the corresponding field. Ensure that this number is accurate for proper identification.
5. Proceed to the 'Functional Examination Record' section, and fill out the details regarding posture, dermatomes, and pain/light touch assessments for the upper extremities.
6. In the 'Range of Motion (ROM)' section, record the relevant values for each joint, including elevating, depressing, and protecting movements for the shoulder and elbow.
7. Fill out the strength assessment for both right and left sides of the body, marking the appropriate levels.
8. Complete the reflexes section, indicating whether responses are normal for each area tested, both right and left.
9. Document the myotomes evaluated during the examination, ensuring both sides are recorded accurately.
10. Continue with the cranial nerve tests, marking the results for each test conducted.
11. Assess tenderness to palpation in the specified areas and indicate findings clearly.
12. Finally, review all information for accuracy before submitting. Once completed, you can save changes, download, print, or share the form as required.

Start completing your documentation online today.