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Subjective:
Initial Comments
Primary complaint
• • •
Mechanism of Injury (T)
Date of Onset
quantify the Onset
VAS
Nature of Pain
• • •
Denies radiating symptoms
Radiating symptoms are (T)
Relief
• • •
Provocative
• • •
Frequency
Timing
• • •
No other care before toay.
Other Doctors
• • •
Night sweats / Unexplained Weight Loss
Sleep
Other comments
Disability index % (T)
History of Illness
Secondary complaint
• • •
Onset (T)
VAS
Mechanism of Injury
Relief
• • •
Provocative
• • •
Denies radiating symptoms
Radiating symptoms are
Frequency
Timing
• • •
History of Illness
Other comments
Disability index % (T)
3rd complaint ALL (T)
Disability index % (T)
4th complaint (T)
Disability index % (T)
Objective
DTR normal
DTR not normal
• • •
Gait
• • •
Distress/tired
• • •
C/S
Muscle spasms
• • •
muscle tendernes
• • •
fluid motion
• • •
Pain?
• • •
Cervical ROM
• • •
Pain?
• • •
Posture/observation
• • •
Trigger points location (T)
Comment
Cervical Spine Orthopedic Tests
Max cervical compression
• • •
Shoulder depressor
• • •
Cervical distraction
• • •
Cervical compression
• • •
Dekleyn's
• • •
Bakody's
• • •
upper extermity sensory exam
• • •
Upper extremity strength
• • •
Comment
Other Orthopedics (T)
Thoracic:
Thoracic posture
• • •
fluid motion
• • •
Pain?
• • •
Muscle spasms
• • •
muscle tendernes
• • •
Rib motion
• • •
Adams Sign
Soto Halls
• • •
Trigger points location (T)
Comment
Other Orthopedics (T)
L/S:
Dorsolumbar ROM
• • •
Pain?
• • •
fluid motion
• • •
Pain?
• • •
muscle spasms
• • •
pain?
• • •
leg length (short)
Sensory exam
• • •
Posture
• • •
Trigger points location (T)
Pelvis
• • •
Comment
Lumbar Spine Orthopedic Tests
FABERE's
• • •
SLR
• • •
radiating with SLR
• • •
Slump test
• • •
Trendelenburg
Toe Walk
Heel Walk
Yeomans
Kemps test
• • •
Other Orthopedics(T)
Shoulder Exam
Observation
• • •
Shoulder ROM
• • •
Muscle palpation
• • •
Upper extremity strength
• • •
upper extermity sensory exam
• • •
Shoulder orthopedic exams
Speeds Test
• • •
Empty Can
• • •
Dawburns Test
• • •
Hawkin's - Kennedy
• • •
Yergason's Test
• • •
Other orthopedic tests (T)
Elbow/Wrist/Hand
Observation:
• • •
Palpation of muscles
• • •
Elbow ROM and pain
• • •
Hand/finger ROM and pain
• • •
Wrist ROM
• • •
Wrist pain
• • •
Elbow Orthopedics
• • •
Other Orthopedics (T)
Knee/Ankle/Foot
Observation:
• • •
Palpation (Spasm)
• • •
Ankle ROM
• • •
ankle pain?
• • •
Knee ROM and pain
• • •
Foot/toes ROM and pain
• • •
Knee Orthopedics
• • •
Ankle Orthopedics
• • •
Other comments (T)
Other Orthopedics (T)
ASSESSMENT
• • •
prognosis fair/poor
• • •
ST Goals:______
LT goals
Comments
PLAN
• • •
T/S:____
• • •
C/S:____
• • •
L/S:____
• • •
SI
• • •
extremity adj type it out
Ice
Kinesio Tape
• • •
Graston Area
• • •
Graston time
Therapeutic Exercise: Areas___
• • •
Therapuetic stretches
• • •
Treatment plan
• • •
Follow up on
• • •
Change in treatment plan
Treated by
Chiropractic Adjustments 98940
• • •
Chiropractic Adjustments 98941
• • •
Extraspinal Adjustments 98943
• • •
Records reviewed
• • •
Therapeutic Exercise 97110 59
• • •
Radiology
• • •
Supplies
• • •
Cold/Hot Pack 97010
• • •
Ultrasound Therapy 97035
• • •
Laboratory
• • •
Electrical Stim Attended 97032
• • •
Manual Therapy Techniques 97140
• • •

Chiropractic Initial Evaluation Medical Form

Chiropractor

Initial/reexam chiro

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Published: Aug. 5, 2016, 8:22 a.m.
Doctor: Dr. History Physical
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