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Chief Complaint
• • •
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Chief Complaint Comments
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PREGNANT
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Weeks Pregnant
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CC status
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CC Status Comments
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% of day?
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% of the day Comments
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Pain Rating
• • •
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Symp. worst when?
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Quality of pain
• • •
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Quality of Pain Comments
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Spinal Palpation
• • •
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Timing of Symptoms Comments
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Muscle Pain/Tenderness/Spasms
• • •
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Spinal Palpation Comments
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Range of motion
• • •
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Gait
• • •
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Derifield Leg Check
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Subluxations special comments
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Subluxations
• • •
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Pregnant/Websters
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Techniques
• • •
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Wellness Adjustment
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Function
• • •
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Ice
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Plan- improving
• • •
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Core Stability Exercises
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Plan-at home
• • •
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Psoas Stretch form
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Spinal Diagram
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Posture/Rehab Printout
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Clinical Spinal Photo
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Stretches
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Surface emg test
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Spinal Palp WNL
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Treatment Frequency
• • •
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Scan performed
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Office Visit
• • •
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PIRIFORMIS
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Chiropractic Adjustments 98941
• • •
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Records reviewed
• • •
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Extraspinal Adjustments 98943
• • •
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Referrals
• • •
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Manual Therapy Techniques 97140
• • •
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Massage Frequency
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Re-evaluation
• • •
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X-RAYS
• • •
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Assessment Comments
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Prognosis
• • •
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Supplies
• • •
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Massage Therapy 97124 59
• • •
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Therapeutic Activity 97530 59
• • •
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Vibratory Massage 97124 59
• • •
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Cold/Hot Pack 97010
• • •
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Chiropractic Adjustments 98940
• • •
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