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

Integrative Chiropractic: Spinal Ortho/Neuro Medical Form

Chiropractor

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Published: Sept. 30, 2016, 6:08 p.m.
Doctor: Dr. History Physical
Rating: +31   /

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