SF528

MUSCLE FUNCTION BY NERVE DISTRIBUTION: Face, Neck, and Upper Extremity

Agency
GSA
Revision
Rev. 6/1994
Fillable fields
480
Pages
2
Official source
GSA form page
Checked
October 20, 2026
Fill SF528 online
Page 1 of form SF528

Standard Form 528 (SF 528): Muscle Function by Nerve: Face, Neck, and Upper Extremity

Standard Form 528 (SF 528), Muscle Function by Nerve Distribution: Face, Neck, and Upper Extremity, is a two-sided medical record printed as SF Form 528 (Rev. 6-94). The footer of the front names the General Services Administration, and GSA hosts a copy in its forms library. The form prints no prescribing regulation.

The front holds the problem and brief clinical history, a key to manual muscle evaluation, and rows of muscles grouped under their nerves, from the spinal accessory nerve to the radial nerve, each with spinal levels such as C5-6 printed beside it. The back continues with more arm and hand muscles, the median and ulnar nerves, and five muscles of the face with their own key.

The PDF prints no instructions. You can fill it out free in your browser on this page and download the result without an account.

Top of page 1 of Standard Form 528 (SF 528): Muscle Function by Nerve: Face, Neck, and Upper Extremity, as printed by GSA

What's on SF 528

History and muscle key

A PROBLEM AND BRIEF CLINICAL HISTORY block and a KEY TO MANUAL MUSCLE EVALUATION from 100% 5 N Normal down to 0% 0 0 Zero.

Neck and shoulder girdle nerves

Cervical erector spinae, then muscles under the spinal accessory, dorsal scapular, long thoracic, thoracodorsal, and upper and lower subscapular nerves.

Chest, shoulder and arm nerves

Muscles under the ant. thoracic, suprascapular, axillary, musculocutaneous and radial nerves, from the pectoralis major to Ext. Carp. Uln.

Back: forearm and hand

More extensor rows from Ext. Dig. Minimi to Abd. Pol. Long, then the median nerve and ulnar nerve groups down to the palmar interossei.

Back: muscles of face

Frontalis, Orb. Oculi, Procerus, Zygomaticus and Orb. Oris, each marked CR7, with a key for facial muscles: N normal, SN subnormal, T trace and O zero.

Comments, signature and identification

A COMMENTS column on both sides, SIGNATURE and DATE rows, the patient's identification, and register and ward numbers.

How to fill out SF 528

  1. 1

    Write the history

    Fill in the problem and brief clinical history at the top of the front.

  2. 2

    Date the column and side

    Enter the date and the side tested at the head of a column, on the front and on the back.

  3. 3

    Grade each muscle

    Enter results in the row for each muscle. The key on the front gives the grades 5 N, 4 G, 3 F, 2 P, 1 T and 0.

  4. 4

    Grade the face

    Use the muscles of face rows on the back. The key for facial muscles gives N, SN, T and O.

  5. 5

    Comment and sign

    Use the COMMENTS column, then sign and date in the SIGNATURE and DATE rows.

  6. 6

    Identify the patient

    Complete the patient's identification with the register and ward numbers at the foot of the front.

These steps follow the order of the blocks on the two pages.

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Where it goes and what the form says

Where it goes

The PDF prints no filing address. It is labeled Medical Record, and the identification block names the hospital or medical facility.

Issuer and edition

The footer of the front reads GENERAL SERVICES ADMINISTRATION and SF Form 528 (Rev. 6-94). No prescribing regulation is printed, and GSA's page leaves the authority blank.

Instructions and privacy

The PDF prints no instructions, Privacy Act statement or burden estimate.

Related forms

Who fills out SF 528?

  • The person who signs

    The front has SIGNATURE and DATE rows below the COMMENTS column. The form does not name a role for the signer.

  • Dated test columns

    A DATE row and an INDICATE SIDE TESTED row, each marked with an arrow, head six columns of boxes on each side of the form.

  • The patient, as identified

    The patient does not sign. The identification block takes name (last, first, middle), ID no. (SSN or other), and hospital or medical facility.

  • The medical facility

    The form is labeled Medical Record and carries REGISTER NO. and WARD NO. boxes beside the patient's identification.

The form prints no instructions. Its blocks show who signs and whose record it is.

Official sources and the blank

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Questions about Form SF528

Who issues SF 528?

The footer of the front names the General Services Administration and reads SF Form 528 (Rev. 6-94). GSA hosts a copy in its forms library.

How is SF 528 organized?

Muscles are grouped under the nerve that supplies them, such as the axillary, radial, median and ulnar nerves, with spinal levels such as C5-6 or C8, T1 printed beside each muscle.

What grades does SF 528 use?

The key to manual muscle evaluation runs from 100% 5 N Normal to 0% 0 0 Zero. The facial muscles have their own key: N normal, SN subnormal, T trace and O zero.

Who signs SF 528?

The front has SIGNATURE and DATE rows. The form does not name a role for the signer.

Does SF 528 come with instructions?

No. The PDF prints only the form's labeled blocks and the two keys.