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Chief Complaint
• • •
Chief Complaint Comments
Office Visit
• • •
Office Visit Comments
CC status
CC Status Comments
VAS
• • •
VAS Status Comments
% of day?
% of the day Comments
Quality of pain
• • •
Quality of Pain Comments
Relieving Factors
• • •
Relieving Factors Comments
Aggravating Factors
• • •
Aggravating Factors Comments
Symp. worst when?
Timing of Symptoms Comments
Pre-Adjustment Supine Leg Check
• • •
Post-Adjustment Supine Leg Check
• • •
Pre-Adjustment Lumbar Paraspinal Palp
• • •
Post-Adjustment Lumbar Paraspinal Palp
• • •
Pre-Adjustment C2 DNRG Scan
• • •
Post-Adjustment C2 DNRG Scan
• • •
Activator Type
• • •
Spinal Palpation
• • •
Spinal Palpation Comments
Muscle Pain/Tenderness/Spasms
• • •
Gait
• • •
Posture Analysis
• • •
Range of motion
• • •
Derifield Leg Check
Prone Hip Extension
• • •
Cervical Subluxation Complex
• • •
Subluxation Complex
• • •
Pregnant/Websters
Spinal Palp WNL
Occiput
• • •
Thoracic Subluxation Complex
• • •
C1
• • •
T1
• • •
C2
• • •
T2
• • •
C3
• • •
T3
• • •
C4
• • •
T4
• • •
C5
• • •
T5
• • •
C6
• • •
T6
• • •
C7
• • •
T7
• • •
T8
• • •
Lumbar Subluxation Complex
• • •
T9
• • •
L1
• • •
T10
• • •
L2
• • •
T11
• • •
L3
• • •
T12
• • •
L4
• • •
L5
• • •
Right Ilium
• • •
Left Ilium
• • •
Function
• • •
Sacrum
• • •
PIRIFORMIS
Coccyx
• • •
Plan- improving
• • •
Plan-at home
• • •
Referrals
• • •
Treatment Frequency
• • •
Psoas Stretch form
Treatment Schedule
• • •
Core Stability Exercises
Ice
Chiropractic Adjustments 98940
• • •
Chiropractic Adjustments 98941
• • •
Chiropractic Adjustments 98942
• • •
Extraspinal Adjustments 98943
• • •
Vibratory Massage 97124 59
• • •
Supplies
• • •
X-RAYS
• • •
Manual Therapy Techniques 97140
• • •
Daily Living Activities 97535
• • •
Cold/Hot Pack 97010
• • •
Neuromuscular Re-Ed 97112 59
• • •

UUCC SOAP Medical Form

Chiropractor

EPIC Upper Cervical Chiropractic SOAP

There are 2 copies in use.
Published: April 14, 2016, 4:04 p.m.
Doctor: Dr. History Physical
Rating: 0   /

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