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Exam Type:
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No Accident:
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Date of Accident:
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Body parts injured:
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Accident Info:
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MRI:
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Subjective:
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CHIEF COMPLAINT:
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Main Problem Dictation:
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Pain Level:
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Pain Level Change F/U:
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Onset:
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ONSET NO ACCIDENT
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Pain Description:
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Duration:
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Heartburn:
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Current Meds for low back:
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On blood thinners:
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Maximum Site of Pain:
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Radiating Pain/Paresthesia:
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Radiating/Paresthesia Area:
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Increased Pain:
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Decreased Pain:
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F/U Spasms:
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F/U Muscle Relaxers:
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Epidural:
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Epidurals Help:
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TNS:
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TNS Hours Used:
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Home PT:
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Home PT Helping:
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Back Brace:
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Brace Help:
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No Prior Treatment:
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Prior Treatment
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Prior Treatment Consisted of:
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No Pre-Existing:
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Pre-existing condition:
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Pre-Existing Aggravation:
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Bowel/bladder problems:
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Objective:
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Exam deferred to next visit:
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Legs Equal Length:
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Pelvis Level:
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Palpation for low back:
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Poor squatting tech::
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Right Straight Leg Raising - Sitting Position:
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Dorsiflexion:
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Left Straight Leg Raising - Sitting Position:
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Dorsiflexion:
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Straight Leg Raises with Diversion:
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Flexion-Abduction/Ext Rotation of Hips:
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Normal Sensation:
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Decreased Sensation of the Legs:
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Muscle Strength Normal:
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Muscle Strength Decreased:
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Left Knee Reflexes Decreased:
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Right Knee Reflexes Decreased:
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Left Ankle Reflexes Decreased?
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Right Ankle Reflexes Decreased?
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Pinch Test:
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Pinch Test Comment:
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Clonus:
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Spastic muscle:
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Hyperactive reflexes:
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Babinski:
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Correlation No Previous Problem:
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Correlation Previous Problem
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X-Rays:
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X-Ray Results:
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Xray Dictation:
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MRI REVIEWED:
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MRI Dictation:
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Assessment:
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Assessment:
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Assessment Comments:
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2ndry to MVA:
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MVA Aggravated PP:
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2ndry to slip & fall:
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Slip & fall aggravated PP:
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Plan:
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Return Appointment:
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Work Status:
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Disposition:
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No Work:
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PT 1X Visit:
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Continue:
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Stressed home/formal PT:
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Durable Medical Goods:
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Counseled in smoking:
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Schedule Formal PT:
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Discussion MRI'S/Epidurals
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WT DISCUSSION AGREED/DECLINED:
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KASPER:
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Heartburn:
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Patient currently in Pain Management:
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Stop Meds:
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Medications:
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Continue meds other source:
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No Meds:
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Cautioned Medication:
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Prognosis:
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C & I blood thinners:
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Patient is released:
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Final Discharge Options:
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