|
Chief Complaint
• • •
|
Chief Complaint status
|
|
% of day?
|
Other Symptoms
• • •
|
|
Severity of headache
|
Severity of cervical pain
|
|
Severity of thoracic pain
|
Severity of low back pain
|
|
Severity of extremity pain
|
Quality of pain
• • •
|
|
Radiate?
|
If yes, Where?
|
|
Relieving Factors
• • •
|
Aggravating Factors
• • •
|
|
Symp. worst when?
|
Pregnant/Websters
|
|
|
Spinal Palp WNL
|
|
Thermography Scan Performed?
|
Thermography Scan in Pattern?
|
|
Cervical Motion Palpation
• • •
|
Cervical Subluxation Complex
• • •
|
|
R Spasm and Tenderness
• • •
|
Range of motion
• • •
|
|
L Spasm and Tenderness
• • •
|
Posture Analysis
• • •
|
|
Prone Leg Length Inequality
|
Amt of Leg Length Inequality
|
|
Derefield Leg Check
|
Cervical Syndrome Observed?
|
|
|
Cervical Syndrome -- LLI changed to
|
|
Modified Prill Leg Checks
|
Blair X-ray Information
|
|
C1 - Vertical Prill Leg Check
|
Date of X-rays
|
|
C2 - Rotational Prill Leg Check
|
Atlas Plane Line
|
|
C3 - Medial Prll Leg Check
|
Left/Right Convergence Angles on BP
/
|
|
C4 - Lateral Prill Leg Check
|
Right Slope/Left Convexity on Right PV
/
|
|
C5 - Prill Leg Check
|
Left Slope/Right Convexity on Left PV
/
|
|
Blair Listings
|
Correction Performed at Visit?
|
|
C1 Listing
|
C1 Correction
|
|
C2 Listing
|
C2 Correction
|
|
C3 Listing
|
C3 Correction
|
|
C4 Listing
|
C4 Correction
|
|
C5 Listing
|
C5 Correction
|
|
C6 Listing
|
C6 Correction
|
|
|
|
|
Post Thermography Scan Performed?
|
Pattern Observed Post Correction?
|
|
|
|
|
Plan- improving
• • •
|
Treatment Schedule
• • •
|
|
Plan-at home
• • •
|
Function
• • •
|
|
Wellness Care Provided
|
|
