The CE provider will describe and discuss, as appropriate:

a. Character, location, and radiation of pain;

b. Factors that incite and relieve the pain;

c. Symptoms of weakness, other motor loss, and/or any sensory abnormalities; and

d. Dates and results of any relevant diagnostic procedures, such as x-rays, myelography, CT scan, MRI, and radionuclide bone scan.

The CE provider will describe and discuss, as appropriate:

a. Any apparent abnormalities such as gait, or the need for any type of assistive device;

b. Extremities and peripheral joints:

1. Active and passive range of motion;

2. If active range of motion is abnormal, describe passive range of motion and how active range of motion differs from passive range of motion;

3. Effusion;

4. Peri-articular swelling;

5. Pain, if any, and its distribution;

6. Tenderness;

7. Redness or heat;

8. Thickening;

9. Structural deformities;

10. Instability;

11. Grip, pinch, ability to close the fist or perform fine and gross manipulations (measured either by dynamometer or 0-5 scale);

12. Extremity strength (measured either by dynamometer or 0-5 scale);

13. Atrophy; and

14. Ability to use, and effective use of, any orthoses.

c. Spine:

1. Distribution of pain, tenderness, and sensory and/or motor loss;

2. Intensity and symmetry of deep tendon reflexes;

3. Muscle spasms, when present;

4. Active range of spinal motion;

5. When the lumbar spine is an issue, straight-leg raising (lumbar spine, both sitting and supine); and,

6. When the cervical spine is an issue, provocative test for radiculopathy, such as the Sperling test.

d. Amputated extremities:

1. Description of stump, including integrity of skin flap;

2. Tenderness; and

3. Ability to use, and effective use of, any prostheses. It is not necessary to evaluate the child’s ability to walk without the prostheses in place. If an upper extremity is involved, the CE provider should comment on the functional level of the contralateral extremity.

e. Fractures of bones of extremities or pelvis:

1. Review of imaging such as x-rays or MRI; and

2. Clinical evidence of union or non-union.

f. Soft tissue injuries/burns:

1. Nature and extent of the injury;

2. Skin sensitivity; and

3. Effect the injury has on joint motion.