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SMORE (Spinal Mobilization Restriction Evaluation) Worksheet

 
 
Franklin County Public Safety
 SMORE(Spinal Mobilization Restriction Evaluation) Worksheet
 
Patient Initials:________              Age:___/___/___                
 
Date Event:___/___/___                PPCR#:___________
 
Unit #:_________                          
 
Provider Name:________________________                        Number:______________
 
 
 
 
                                                                                                                           
Manual stabilization of C-Spine during evaluation
 
 
 
Yes
No
Major Trauma:
Obvious significant force and injuries, airway concerns, hypotension, multiple long bone fractures, fall >15 ft, ejection from a vehicle, etc
 
 
AGE:   <12 or > 65 years old with significant injury force for age
 
 
Altered Mental Status/Communication:
 Confusion, Dementia or Alzheimer’s, Retardation
 Language, speech or communication problem
 Combativeness, hysteria, psychiatric disorders
 
 
Intoxication: Alcohol or Drugs
 
 
Head Injury: resulting in LOC
 
 
Patient’s Symptoms/Complaint:
 Cervical, Thoracic or Lumbar pain.
 Extremity numbness, tingling, burning or parasthesia.
 Patient complains or extremity weakness or paralysis
 
 
Physical Exam:
 Any spinal pain on palpation.
 Deformity to the spine on palpation or significant external trauma over the spine.
 Extremity weakness, paralysis, numbness, tingling, burning or parasthesias.
 
 
Distracting Injury: Long bone fracture or other painful injury
 
 
Range of Motion (ROM): complaint of pain with
  Flexion/Extension-chin to chest and looking up
 Rotation-Chin to Shoulder
 
 
 
  • Any Yes answer, apply SMR. 
All answers NO, patient excluded from SMR
 
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