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History/Subjective:
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Initial Comments
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Area of pain
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Provocative
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Onset
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Palliative
• • •
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Date of Onset
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Radicular Symptoms
• • •
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Mechanism of Injury
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VAS
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Nature of Pain
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Other Doctors Seen
• • •
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Previous Treatment
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History of Problem
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Frequency
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AM/PM
• • •
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Other comments
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Sleep
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Objective
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Observation:
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Gait
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C/S
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Cervical AROM:
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Palpation:
• • •
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Flexion
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With Pain?
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Extension
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With Pain?
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Rt. Rot
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With Pain?
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Lt. Rot
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With Pain?
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Lt.Lat. Flex
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With Pain?
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Rt.Lat. Flex
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With Pain?
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U.E. Strength
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All Strength Normal
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Left C5 shoulder abduction
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Rt. C5 Shoulder Abduction
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Left C6 elbow flexion/wrist extension
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Rt. C6 Elbow flexion and wrist extension
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Left C7 elbow extension/wrist flexion
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Rt. C7 Elbow extension and wrist flexion
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Left C8 finger flexion
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Rt. C8 Finger flexion
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Left T1 finger abduction
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Rt. T1 Finger abduction
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L.E. Strength
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Left Hip Flexion: L2/3
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Right Hip Flexion: L2/3
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Left Knee Extension: L3/4
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Right Knee Extension: L3/4
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Left Ankle Dorsiflexion: L4/L5
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Right Ankle Dorsiflexion: L4/L5
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Left Great Toe Dorsiflexion: L5
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Right Great Toe Dorsiflexion: L5
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Left Ankle Dorsiflexion: S1
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Right Ankle Dorsiflexion: S1
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DTRs
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All Normal DTR?
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Lt C5
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Rt. C5
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Lt. C6
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Rt. C6
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Lt. C7
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Rt. C7
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Lt. L4
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Rt. L4
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Lt. S1
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Rt. S1
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Cervical Spine Orthopedic Tests
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Cervical Compression Test
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C/S Max compression
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Shoulder Depression Test
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Cervical Distraction
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Adsons
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Comments
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Thoracic:
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Lt. Rot
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Rt. Rot
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Visual:
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Palpation
• • •
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Adams Sign
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Spinous Percussion
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Comments
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L/S:
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Lumbar AROM:
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Flexion
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Extension
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Lt. Rot
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Rt. Rot
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Lt.Lat. Flex
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Rt.Lat. Flex
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Lumbar Spine Orthopedic Tests
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Kemps Test
• • •
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Becterew Test
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Palpation
• • •
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SLR
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Palpation (Spasm)
• • •
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Braggards
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Heel Walk
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Milgram's
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Toe Walk
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Comment
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Pelvis
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Pelvis
• • •
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Yeomans
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Patrick FABER
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Nachlas Test
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Trendelenburg
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Ely's Test
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Comment
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Shoulder Exam
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Shoulder orthopedic exams
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Neer's test
• • •
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Palpation
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Speeds Test
• • •
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Palpation (Trigger Points)
• • •
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Empty Can
• • •
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Dawburns Test
• • •
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Yergason's Test
• • •
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Hawkin's - Kennedy
• • •
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Elbow/Wrist/Hand
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Observation:
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Palpation (Spasm)
• • •
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Elbow/Wrist/Hand AROM
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Right Elbow Extension
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Right Elbow Flexion
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Left Elbow Extension
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Left Elbow Flexion
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Right Forearm Pronation
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Right Forearm Supination
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Left Forearm Pronation
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Right Forearm Supination
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Right Wrist Extension
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Right Wrist Flexion
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Left Wrist Extension
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Left Wrist Flexion
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Knee/Ankle/Foot
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Observation:
• • •
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Palpation (Spasm)
• • •
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Knee/Ankle/Foot AROM
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Right Knee Extension
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Right Knee Flexion
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Left Knee Extension
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Left Knee Flexion
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Right Ankle Dorsiflexion
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Right Ankle Plantarflexion
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Left Ankle Dorsiflexion
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Left Ankle PlantarFlexion
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Assessment
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Diagnosis
• • •
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Comments on DX
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Prognosis
• • •
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Comments
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Plan:
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Treatment Frequency month:
• • •
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Treatment Duration Month
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Treatment Frequency Weeks:
• • •
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Treatment Duration week
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Re-examination:
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Chiropractic Adjustments 98940
• • •
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Manual Therapy Techniques 97140
• • •
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Therapeutic Exercise 97110 59
• • •
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Mechanical Traction 97012
• • •
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Non-Surgical Spinal Decompression S9090
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Ultrasound Therapy 97035
• • •
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Electrical Stim Attended 97032
• • •
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Extraspinal Adjustments 98943
• • •
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Cold/Hot Pack 97010
• • •
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Neuromuscular Re-Ed 97112 59
• • •
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Supplies
• • •
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Radiology
• • •
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Laboratory
• • •
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Records reviewed
• • •
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Comments
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