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History
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Location
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Onset
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Aggravating factors
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Relieving factors:
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Intensity
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Quality:
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Duration:
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Radiation:
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Frequency/Timing:
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Prior injury to area of complaint:
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Treatment and course of injury:
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Past medical history:
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Occupation:
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Lifestyle
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Relevant family history
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Red Flags
• • •
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Other information
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Observation (Posture, gait)
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Ranges of motion:
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Human body diagram
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Orthopedic tests
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Cervical
• • •
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Comments
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Thoracic
• • •
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Comments
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Lumbar
• • •
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Comments
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Shoulder
• • •
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Comments
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Elbow
• • •
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Comments
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Wrist/hand
• • •
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Comments
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Hip
• • •
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Comments
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Knee
• • •
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Comments
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Ankle/toes
• • •
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Comments
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Cranial Nerve Test
• • •
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Comments
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Neurological tests: Reflexes
• • •
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Comments
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Myotome:
• • •
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Comments
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Dermatome
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Plan of Management
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Acupuncture/Moxa:
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Mobilization:
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Manipulation:
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Soft tissue treatment:
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Active care:
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Frequency/Duration:
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