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Subjective
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Home Care Kit
|
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Office Visit MAN 1-2
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Office visit MAN 3-4
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Joint Mob JM
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|
|
|
|
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Chief Complaint
• • •
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Chief Complaint Comments
|
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CC status
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CC Status Comments
|
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Pain Scale
|
|
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% of day?
|
% of the day Comments
|
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Quality of pain
• • •
|
Quality of Pain Comments
|
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Relieving Factors
• • •
|
Relieving Factors Comments
|
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Aggravating Factors
• • •
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Aggravating Factors Comments
|
|
Symp. worst when?
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Timing of Symptoms Comments
|
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Objective Findings
|
|
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Muscle Pain/Tenderness/Spasms
• • •
|
Posture Analysis
• • •
|
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Gait
• • •
|
|
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Range of motion
• • •
|
Range of Motion Comments
|
|
Treatment Schedule
• • •
|
Function Comments
|
|
Cervical Orthopedic tests
|
Other Orthopedic Test
|
|
Cervical Orthopedic Tests
|
|
|
Maximal Compression
• • •
|
Comments
|
|
Cervical Compression
• • •
|
Comments
|
|
Cervical Distraction
• • •
|
Comments
|
|
Shoulder depression
• • •
|
Comments
|
|
Other Orthopedic Test
|
Comments
|
|
Thoraco-Lumbar Orthopedic tests
|
|
|
Thoraco-Lumbar Orthopedic Tests
|
|
|
Valsalva
• • •
|
Comments
|
|
Trendelenburg
• • •
|
Comments
|
|
Slump Test
• • •
|
Comments
|
|
SLR active/passive
• • •
|
Comments
|
|
Bragard's
• • •
|
Comments
|
|
Kemp's
• • •
|
Comments
|
|
Leg length
|
Comments
|
|
Patrick FABERE
• • •
|
Comments
|
|
Hibb's Test
• • •
|
Comments
|
|
Yeoman's Test
• • •
|
Comments
|
|
ADJUSTMENT(S)
|
Spinal Palpation Comments
|
|
Adjustments to:
|
|
|
Manipulations/Mobilizations
|
Cervical
• • •
|
|
Manipulations/Mobilizations
|
Thoracic
• • •
|
|
Manipulations/Mobilizations
|
Lumbar
• • •
|
|
Manipulations/Mobilizations
|
Sacrum
• • •
|
|
Manipulations/Mobilizations
|
Pelvis
• • •
|
|
Manipulations/Mobilizations
|
Lower Extremity
• • •
|
|
Manipulations/Mobilizations
|
Upper Extremity
• • •
|
|
Manipulations/Mobilizations
|
Extraspinal Adjustments 98943
• • •
|
|
|
Other
|
|
Asssessment
|
|
|
Assessment
• • •
|
Comments
|
|
Plan
|
|
|
Plan- improving
• • •
|
Comments
|
|
Plan-at home
• • •
|
|
|
X-RAYS
• • •
|
Xray Comments
|
|
Orthotics Fit 97504
|
Orthotics L3000-RT and L3000-LT
|
