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New patient PT exam
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New Patient Chiro exam
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New Patient PT Exam - Level 1
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NP Chiro Exam level 1
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New Patient PT Exam - Level 2
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NP Chiro Exam Level 2
|
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New Patient PT Exam- Level 3
|
NP Chiro Exam Level 3
|
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RE- EXAM PT
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Re-exam chiro
|
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Re- Exam level 1
|
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Re-Exam Level 2
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Home Care Kit
|
Re-Exam Level 3
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Date of Exam
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Pain Diagram
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Observation
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Observation WNL
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Bruising
|
[+] Bruising Comments
• • •
|
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Swelling
|
[+] Swelling Comments
• • •
|
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Redness
|
[+] Redness Comments
• • •
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Skin (bruising, scars)
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Comments
|
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Posture/Gait
|
|
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Antalgia
|
[+] Antalgia Comments
• • •
|
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ABN Posture
• • •
|
ABN Leg Length
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Step Deformity
|
[+] Step Deformity Comments
• • •
|
|
Scoliosis
|
[+] Scoliosis Comments
• • •
|
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Trendelenburg's Sign
|
[+] Trendelenburg's Sign
• • •
|
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Palpation
|
|
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Palpation:
• • •
|
Comments
|
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Abdomen
|
Comments
|
|
Inguinal lymph nodes
|
Comments
|
|
Skin temperature
|
Comments
|
|
Pubic symphysis
|
Comments
|
|
ASIS
|
Comments
|
|
Iliac crest
|
Comments
|
|
Paraspinal muscles
|
Comments
|
|
Quadratus lumborum
|
Comments
|
|
Sciatic notch
|
Comments
|
|
PSIS
|
Comments
|
|
Ischial tuberosities
|
Comments
|
|
Hamstrings
|
Comments
|
|
TFL
|
Comments
|
|
Greater trochanter
|
Comments
|
|
Piriformis
|
Comments
|
|
Sacrotuberous lig.
|
Comments
|
|
Sacroiliac joint
|
Comments
|
|
Sacrospinous lig.
|
Comments
|
|
Gluteus maximus
|
Comments
|
|
Gluteus medius
|
Comments
|
|
Quadriceps
|
Comments
|
|
Gastro-soleus
|
Comments
|
|
Abnormal motion:
|
Comments
|
|
Joint Disfunction
|
|
|
T12
|
Comments
|
|
L1
|
Comments
|
|
L2
|
Comments
|
|
L3
|
Comments
|
|
L4
|
Comments
|
|
L5
|
Comments
|
|
S1
|
Comments
|
|
Lumbar ROM Exam
|
ROM WNL
|
|
Flexion (60)
|
Flexion Symptoms
• • •
|
|
Extension (25)
|
Extension Symptoms
• • •
|
|
Left Lateral Flexion (25)
|
LLF Symptoms
• • •
|
|
Right Lateral Flexion (25)
|
RLF Symptoms
• • •
|
|
Left Rotation (10)
|
LR Symptoms
• • •
|
|
Right Rotation (10)
|
RR Symptoms
• • •
|
|
Neurologic
|
|
|
DTR
|
DTR WNL
|
|
Babinski Reflex
• • •
|
|
|
Left L4
|
Right L4
|
|
Left S1
|
Right S1
|
|
Sensation
|
Sensation WNL
|
|
Type of Sensation Test
• • •
|
|
|
Left L4 Dermatome
|
Right L4 Dermatome
|
|
Left L5 Dermatome
|
Right L5 Dermatome
|
|
Left S1 Dermatome
|
Right S1 Dermatome
|
|
Motor Function
|
Motor Function WNL
|
|
Left L3 Myotome - Knee Ext
|
RIght L3 Myotome - Knee Ext
|
|
Left L4 Myotome - Ankle Inv
|
RIght L4 Myotome - Ankle Inv
|
|
Left L5 Myotome - Hallux Ext
|
Right L5 Myotome - Hallux Ext
|
|
Left S1 Myotome - Ankle Ev
|
Right S1 Myotome - Ankle Ev
|
|
ABN Heel Walk/ Toe Walk
|
ABN Heel/Toe Walk Comments
• • •
|
|
Orthopedic Tests
|
Orthopedic Tests WNL
|
|
Valsalva Maneuver
|
Comments
|
|
LEFT Kemp's Test
|
[+] LEFT Kemp's Comments
• • •
|
|
RIGHT Kemp's Test
|
[+] RIGHT Kemp's Comments
• • •
|
|
LEFT Slump Test
|
[+] LEFT Slump Test Comments
• • •
|
|
RIGHT Slump Test
|
[+] RIGHT Slump Test Comments
• • •
|
|
LEFT SLR
|
[+] LEFT SLR Comments
• • •
|
|
RIGHT SLR
|
[+] RIGHT SLR Comments
• • •
|
|
LEFT Laguerre's Test
|
[+] LEFT Laguerre's Test
• • •
|
|
RIGHT Laguerre's Test
|
[+] RIGHT Laguerre's Test
• • •
|
|
LEFT FABERE
|
RIGHT FABERE
|
|
Spinous Percussion
|
[+] Spinous Percussion
• • •
|
|
LEFT Yeoman's Test
|
RIGHT Yeoman's Test
|
|
LEFT Hibb's Test
|
RIGHT Hibb's Test
|
|
SIJ Compression
|
[+] SIJ Compression
• • •
|
|
LEFT Stork Test
|
[+] LEFT Stork Test
• • •
|
|
RIGHT Stork Test
|
[+] RIGHT Stork Test
• • •
|
|
DDX Impressions
|
|
