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Chief Complaint
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Chief Complaint Comments
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Office Visit
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Office Visit Comments
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ROM WNL
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Skin Inspection Comments
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CC status
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CC Status Comments
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% of day?
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% of the day Comments
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Pain Rating
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Quality of Pain Comments
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Quality of pain
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Relieving Factors Comments
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Relieving Factors
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Aggravating Factors Comments
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Aggravating Factors
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Timing of Symptoms Comments
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Symp. worst when?
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Records reviewed
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Spinal Palpation
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Spinal Palpation Comments
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Muscle Pain/Tenderness/Spasms
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Posture Analysis
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Gait
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Subluxation Complex
• • •
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Pregnant/Websters
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Spinal Palp WNL
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Range of motion
• • •
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Derifield Leg Check
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Thoracic Subluxation Complex
• • •
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Cervical Subluxation Complex
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Lumbar Subluxation Complex
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T1
• • •
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Occiput
• • •
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T2
• • •
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C1
• • •
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T3
• • •
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C2
• • •
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T4
• • •
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C3
• • •
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T5
• • •
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C4
• • •
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T6
• • •
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C5
• • •
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T7
• • •
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C6
• • •
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T8
• • •
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C7
• • •
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T9
• • •
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T10
• • •
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L1
• • •
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T11
• • •
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L2
• • •
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T12
• • •
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L3
• • •
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L4
• • •
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Right Ilium
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L5
• • •
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Left Ilium
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Sacrum
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Function
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Pelvis
• • •
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PIRIFORMIS
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Plan- improving
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Referrals
• • •
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Plan-at home
• • •
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Treatment Frequency
• • •
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Psoas Stretch form
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Treatment Schedule
• • •
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Core Stability Exercises
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Wellness Adjustment
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Posture/Rehab Printout
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Ice
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Electrical Stim Unattended G0283
• • •
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Ultrasound Therapy 97035
• • •
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Manual Therapy Techniques 97140
• • •
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Parafin 97018
• • •
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Mechanical Traction 97012
• • •
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Electrical Stim Attended 97032
• • •
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Chiropractic Adjustments 98940
• • •
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Stim Pads A4556
• • •
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Chiropractic Adjustments 98941
• • •
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Chiropractic Adjustments 98942
• • •
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Extraspinal Adjustments 98943
• • •
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X-RAYS
• • •
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Therapeutic Exercise 97110 59
• • •
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Supplies
• • •
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Daily Living Activities 97535
• • •
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Massage Therapy 97124 59
• • •
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Neuromuscular Re-Ed 97112 59
• • •
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Therapeutic Activity 97530 59
• • •
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Cold/Hot Pack 97010
• • •
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Gait Training
• • •
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Hydromassage Therapy 97039 59
• • •
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Vibratory Massage 97124 59
• • •
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Spinal Diagram
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Clinical Spinal Photo
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