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This patient presents with the following problem
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Rated their intensity of pain as ____
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Describes their pain with following qualifier
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Describes their symptoms as radiating down the
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to the
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Aggravated by activities involving____
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Some relief is obtained when
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Any comments
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Range of motion/joint fixation:
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Headers
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Active/Passive
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Joint
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Plane of Motion
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Degrees
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Level of Decrease
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With Pain
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Active/Passive
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Joint
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Plane of Motion
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Degrees
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Level of Decrease
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With Pain
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Active/Passive
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Joint
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Plane of Motion
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Degrees
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Level of Decrease
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With Pain
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Active/Passive
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Joint
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Plane of Motion
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Degrees
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Level of Decrease
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With Pain
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Active/Passive
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Joint
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Plane of Motion
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Degrees
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Level of Decrease
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With Pain
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Spinal Alignments
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Header
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Location
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Alignment
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Tenderness to palpation/subluxation was present
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General Assessment
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Phase of healing
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Type of care
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Prognosis:
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Overall Prognosis
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Prognosis Change
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Patient Statements
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Provider Statements
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Spine Levels Adjusted
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Level
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Side
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Technique
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Listing
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Custom
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Level
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Side
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Technique
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Listing
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Custom
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Level
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Side
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Technique
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Listing
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Custom
• • •
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Level
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Side
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Technique
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Listing
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Custom
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Very light MA to the cervical spine
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Patient Care Plan
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Informed Consent Obtained
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Problem
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Frequency
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Duration
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Services
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Benefits
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Conditions to be Monitored
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