|
Subjective
|
Home Care Kit
|
|
Joint Mob JM
|
|
|
Pain Scale
|
Subjective Free text
|
|
% of day?
|
% of the day Comments
|
|
Quality of pain
• • •
|
Quality of Pain Comments
|
|
Relieving Factors
• • •
|
Relieving Factors Comments
|
|
Aggravating Factors
• • •
|
Aggravating Factors Comments
|
|
Symp. worst when?
|
Timing of Symptoms Comments
|
|
Objective Findings
|
Posture Analysis
• • •
|
|
Muscle Pain/Tenderness/Spasms
• • •
|
|
|
Range of motion
• • •
|
Range of Motion Comments
|
|
Cervical Orthopedic tests
|
|
|
Cervical Orthopedic Tests
|
Comments
|
|
Maximal Compression
• • •
|
Comments
|
|
Cervical Compression
• • •
|
Comments
|
|
Cervical Distraction
• • •
|
Comments
|
|
Shoulder depression
• • •
|
Comments
|
|
Other Orthopedic Test
|
|
|
Lumbar Orthopedic tests
|
|
|
Lumbar Orthopedic Tests
|
|
|
Valsalva
• • •
|
Comments
|
|
Trendelenburg
• • •
|
Comments
|
|
Slump Test
• • •
|
Comments
|
|
SLR active/passive
• • •
|
Comments
|
|
Bragard's
• • •
|
Comments
|
|
Kemp's
• • •
|
Comments
|
|
Mobilizations
|
Joint Palpation Comments
|
|
Cervical/Head
• • •
|
|
|
Thoracic
• • •
|
|
|
Lumbar
• • •
|
|
|
Sacrum
• • •
|
|
|
Pelvis
• • •
|
|
|
Lower Extremity
• • •
|
|
|
Upper Extremity
• • •
|
|
|
Other
|
|
|
Other procedures performed? List here
|
|
|
ASSESSMENT
|
|
|
Patient responded well to care?
|
Additional Information
|
|
PLAN
|
|
|
Patient to continue tx plan?
|
No? Explanation Required
|
|
Other Plan?
|
|
