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History/Subjective:
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Pain diagram
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Initial Comments
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Area of pain
• • •
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Location
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Onset
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Date of Onset
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Mechanism of Injury
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VAS
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Palliative
• • •
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Palliative comments
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Provocative
• • •
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Provocative comments
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Nature of Pain
• • •
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Frequency
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Timing
• • •
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Denies Numbness/Tingling
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tingling/numbness
• • •
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No other care before toay.
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Other Doctors
• • •
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History of Illness
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Night sweats / Unexplained Weight Loss
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Sleep
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Other comments
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Objective
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Observation:
• • •
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Gait
• • •
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3 stair climb
• • •
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Other Objective measures:
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U.E. myotomes
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Left C5 shoulder abduction
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Rt.
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Left C6 elbow flexion/wrist extension
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Rt.
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Left C7 elbow extension/wrist flexion
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Rt.
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Left C8 finger flexion
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Rt.
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Left T1 finger abduction
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Rt.
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L.E. Myotomes
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L2/3
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Rt.
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Left L3/4
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Rt.
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Left L4/L5
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Rt.
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L5
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Rt.
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S1 Lt
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Rt.
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DTRs
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Lt C5
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Rt
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Lt. C6
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Rt.
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Lt. C7
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Rt.
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L4 Lt.
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Rt.
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L5 Lt.
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Rt.
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S1 Lt.
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Rt.
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Dermatomes
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C5
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L2
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C6
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L3
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C7
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L4
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C8
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L5
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T1
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S1
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Comment
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Comment
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Pathological Reflex's
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Ankle Clonus
• • •
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Lower extremity Babinski
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Upper extremity Hoffman's
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Tromner’s
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Functional Movement Screen
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Single Leg Stand Left
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Single Leg Stand Right
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Standing Left Knee Lift
• • •
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Standing Right Knee Lift
• • •
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Left Hip Internal Rotation
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Right Hip Internal Rotation
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Left Glut med raise
• • •
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Right Glut med raise
• • •
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Standing Squat
• • •
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Standing OH squat comments
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Wall Push Up
• • •
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Wall Angel
• • •
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Founder
• • •
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Supine Head Lift
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Core assessment
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C/S
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Palpation:
• • •
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Tender to Palpation
• • •
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Cervical ROM:
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Flexion out of 60°
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With Pain?
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Extension out of 60°
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With Pain?
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Rt. Rot out of 80°
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With Pain?
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Lt. Rot out of 80°
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With Pain?
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Lt.Lat. Flex out of 45°
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With Pain?
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Rt.Lat. Flex out of 45°
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With Pain?
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Cervical Spine Orthopedic Tests
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Cervical Compression Test
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Jacksons Cervical test
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Cervical Distraction
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Shoulder Depression Test
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Right Max. C/S compression
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Bakodys
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Left Max. C/S Comp. Test
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Adsons
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cervical Spinal listings
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Occiput
• • •
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C1
• • •
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C2
• • •
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C3
• • •
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C4
• • •
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C5
• • •
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C6
• • •
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C7
• • •
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Thoracic:
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Visual:
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Adams Sign
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Spinous Percussion
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Palpation
• • •
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Tender to Palpation
• • •
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Palpation (Trigger Points)
• • •
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Thoracic Spinal listings
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T1
• • •
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T2
• • •
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T3
• • •
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T4
• • •
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T5
• • •
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T6
• • •
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T7
• • •
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T8
• • •
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T9
• • •
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T10
• • •
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T11
• • •
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T12
• • •
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L/S:
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Palpation
• • •
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Palpation (Spasm)
• • •
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Tender Facets
• • •
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Lumbar AROM:
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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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Lt. Rot
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With pain?
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Rt. 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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Lumbar Spinal listings
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With pain?
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L1
• • •
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L2
• • •
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L3
• • •
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L4
• • •
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L5
• • •
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Pelvis
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Pelvis
• • •
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Sacral
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Sacrum
• • •
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Lumbar Spine Orthopedic Tests
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Trendelenburg
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Valsalva
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Dejerines Triad
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Kemp's Test
• • •
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Minors sign
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Elys Test
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SLR
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Hibbs
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Braggards
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Well Leg Raise
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Milgram's
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Yeomans
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Toe Walk
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Heel Walk
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Slump Test
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Bechterew's
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comments
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Shoulder Exam
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Palpation
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Joint Palpatation
• • •
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Comments
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Shoulder orthopedic exams
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Neer's test
• • •
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Speeds Test
• • •
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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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Comments
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Palpation (Spasm)
• • •
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Palpation (Trigger Points)
• • •
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Elbow/Wrist/Hand AROM
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Comments
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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 (Trigger Points)
• • •
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Palpation (Spasm)
• • •
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Joint Palpation
• • •
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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 per month:
• • •
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Treatment Duration ( how many months)
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Treatment Frequency per week
• • •
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Treatment Duration (how many weeks)
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Re-examination:
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Active Care Rehab
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Chiropractic Adjustments 98940
• • •
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Soft Tissue Work
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Extraspinal Adjustments 98943
• • •
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Radiology
• • •
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Therapeutic Exercise 97110 59
• • •
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Records reviewed
• • •
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Electrical Stim Attended 97032
• • •
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Manual Therapy Techniques 97140
• • •
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Cold/Hot Pack 97010
• • •
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Neuromuscular Re-Ed 97112 59
• • •
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Ultrasound Therapy 97035
• • •
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Mechanical Traction 97012
• • •
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Supplies
• • •
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Laboratory
• • •
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Comments
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