|
New Patient PT Exam - Level 1
|
Home Care Kit
|
|
New Patient PT Exam - Level 2
|
NP Chiro Exam level 1
|
|
New patient PT exam - Level 3
|
NP Chiro Exam Level 2
|
|
|
NP Chiro Exam Level 3
|
|
RE- EXAM PT
|
Re- Exam Chiro level 1
|
|
|
Re-Exam Chiro Level 2
|
|
|
Re-Exam Chiro Level 3
|
|
Date of Exam
|
Pain Diagram
|
|
Observation
|
Observation WNL
|
|
Bruising
|
[+] Bruising Comments
• • •
|
|
Swelling
|
[+] Swelling Comments
• • •
|
|
Redness
|
[+] Redness Comments
• • •
|
|
Posture
|
Posture free text
|
|
Antalgia
|
[+] Antalgia Comments
• • •
|
|
Scoliosis
|
[+] Scoliosis Comments
• • •
|
|
ABN Posture
• • •
|
Comments
|
|
Palpation
|
WNL
|
|
Skin (masses, temp)
|
Comments
|
|
Lymph nodes
|
Comments
|
|
Temporalis
|
Comments
|
|
Masseter
|
Comments
|
|
TMJ
|
Comments
|
|
Scalenes
|
Comments
|
|
SCM
|
Comments
|
|
Levator scapulae
|
Comments
|
|
Trapezius/rhomboids
|
Comments
|
|
Suboccipitals
|
Comments
|
|
Posterior c-spine muscles
|
Comments
|
|
Trachea mobility
|
Comments
|
|
Clavicle / thoracic outlet
|
Comments
|
|
Rotator cuff
|
Comments
|
|
ROM
|
ROM WNL
|
|
C0
|
Comments
|
|
C1
|
Comments
|
|
C2
|
Comments
|
|
C3
|
Comments
|
|
C4
|
Comments
|
|
C5
|
Comments
|
|
C6
|
Comments
|
|
C7
|
Comments
|
|
T1
|
Comments
|
|
T2
|
Comments
|
|
T3
|
Comments
|
|
T4
|
Comments
|
|
T5
|
Comments
|
|
T6
|
Comments
|
|
T7
|
Comments
|
|
T8
|
Comments
|
|
T9
|
Comments
|
|
T10
|
Comments
|
|
T11
|
Comments
|
|
T12
|
Comments
|
|
Cervical Spine ROM Exam
|
|
|
Flexion (60)
|
Flexion Symptoms
• • •
|
|
Extension (60)
|
Extension Symptoms
• • •
|
|
Left Lateral Flexion (45)
|
LLF Symptoms
• • •
|
|
Right Lateral Flexion (45)
|
RLF Symptoms
• • •
|
|
Left Rotation (80)
|
LR Symptoms
• • •
|
|
Right Rotation (80)
|
RR Symptoms
• • •
|
|
Neurologic Tests
|
|
|
DTR
|
DTR WNL
|
|
Babinski Reflex:
• • •
|
|
|
Left C5
|
Right C5
|
|
Left C6
|
Right C6
|
|
Left C7
|
Right C7
|
|
Sensation
|
Sensation WNL
|
|
Type of Sensation Tested
• • •
|
|
|
Left C5 Dermatome
|
Right C5 Dermatome
|
|
Left C6 Dermatome
|
Right C6 Dermatome
|
|
Left C7 Dermatome
|
Right C7 Dermatome
|
|
Left C8 Dermatome
|
Right C8 Dermatome
|
|
Left T1 Dermatome
|
Right T1 Dermatome
|
|
Motor Function
|
Motor Function WNL
|
|
Left C5 Myotome - Shoulder ABD
|
Right C5 Myotome - Shoulder ABD
|
|
Left C6 Myotome - Wrist Ext
|
Right C6 Myotome - Wrist Ext
|
|
Left C7 Myotome - Wrist Flex
|
Right C7 Myotome - Wrist Flex
|
|
Left C8 Myotome - Finger Flex
|
Right C8 Myotome - Finger Flex
|
|
Left T1 Myotome - Finger ABD
|
Right T1 Myotome - Finger ABD
|
|
Grip Strength R/L
/
|
|
|
Othopedic Tests
|
Orthopedic Tests WNL
|
|
|
|
|
Valsalva Maneuver
|
Bakody's Sign
|
|
L'hermitte's Sign
|
|
|
Spinous Percussion
|
[+] Spinous Percussion
• • •
|
|
Cervical Distraction
|
[+] Cervical Distraction Comments
• • •
|
|
LEFT Jackson's Comp.Test
|
[+] LEFT Jackson's Test Comments
• • •
|
|
RIGHT Jackson's Comp.Test
|
[+] RIGHT Jackson's Test Comments
• • •
|
|
LEFT Max. Foraminal Comp.Test
|
[+] LEFT MFC Comments
• • •
|
|
RIGHT Max. Foraminal Comp.Test
|
[+] RIGHT MFC Comments
• • •
|
|
LEFT Shoulder Depression Test
|
[+] LEFT Shoulder Depression
• • •
|
|
RIGHT Shoulder Depression Test
|
[+] RIght Shoulder Depression
• • •
|
|
LEFT O'Donoghue's Maneuver
|
[+] LEFT O'Donoghue's Maneuver
• • •
|
|
RIGHT O'Donoghue's Maneuver
|
[+] RIGHT O'Donoghue's Maneuver
• • •
|
|
DDX Impressions
|
Open/close TMJ test
|
