|
Notes
|
|
|
Handed
|
Temp
|
|
Primary Complaint
|
Others please specify
|
|
Pain Level
|
Does it radiates to any of the following
• • •
|
|
Describe Pain
• • •
|
Others please specify
|
|
Secondary Complaint
|
Others please specify
|
|
Pain Level
|
Does it radiates to any of the following
• • •
|
|
Describe Pain
• • •
|
Others please specify
|
|
Any other concerns
|
|
|
New Patient
|
|
|
CERVICAL
|
Arom
|
|
Flexion (60)
|
Arom
|
|
Extension (75)
|
Arom
|
|
Lt Lat Flex (45)
|
Arom
|
|
Rt Lat Flex (45)
|
Arom
|
|
Lt Rotation (80)
|
Arom
|
|
Rt Rotation (80)
|
Arom
|
|
TEST
|
Arom
|
|
Compression
|
Arom
|
|
Shoulder dep
|
Arom
|
|
Valsalva
|
Arom
|
|
Hyper. Flex/Ext
|
Arom
|
|
LUMBAR
|
Arom
|
|
Flexion (90)
|
Arom
|
|
Extension (30)
|
Arom
|
|
Lt Lat Flex (30)
|
Arom
|
|
Rt Lat Flex (30)
|
Arom
|
|
Lt Rotation (30)
|
Arom
|
|
Rt Rotation (30)
|
Arom
|
|
TEST
|
Arom
|
|
SLR
|
Arom
|
|
Milgram's
|
Arom
|
|
Heel/Toe
|
Arom
|
|
Nachlas
|
Arom
|
|
Pelvic Comp
|
Arom
|
|
For follow up patients
|
|
|
CERVICAL
|
Pain
|
|
CMT
|
LT
|
|
RT
|
Flexion (60)
|
|
Pain
|
CMT
|
|
LT
|
RT
|
|
Extension (75)
|
Pain
|
|
CMT
|
LT
|
|
RT
|
Lt Lat Flex (45)
|
|
Pain
|
CMT
|
|
LT
|
RT
|
|
Rt Lat Flex (45)
|
Pain
|
|
CMT
|
LT
|
|
RT
|
Lt Rotation (80)
|
|
Pain
|
CMT
|
|
LT
|
RT
|
|
Rt Rotation (80)
|
Pain
|
|
CMT
|
LT
|
|
RT
|
TEST
|
|
Pain
|
CMT
|
|
LT
|
RT
|
|
Compression
|
Pain
|
|
CMT
|
LT
|
|
RT
|
Shoulder dep
|
|
Pain
|
CMT
|
|
LT
|
RT
|
|
Valsalva
|
Pain
|
|
CMT
|
LT
|
|
RT
|
Hyper. Flex/Ext
|
|
Pain
|
CMT
|
|
LT
|
RT
|
|
LUMBAR
|
Pain
|
|
CMT
|
LT
|
|
RT
|
Flexion (90)
|
|
Pain
|
CMT
|
|
LT
|
RT
|
|
Extension (30)
|
Pain
|
|
CMT
|
LT
|
|
RT
|
Lt Lat Flex (30)
|
|
Pain
|
CMT
|
|
LT
|
RT
|
|
Rt Lat Flex (30)
|
Pain
|
|
CMT
|
LT
|
|
RT
|
Lt Rotation (30)
|
|
Pain
|
CMT
|
|
LT
|
RT
|
|
Rt Rotation (30)
|
Pain
|
|
CMT
|
LT
|
|
RT
|
TEST
|
|
Pain
|
CMT
|
|
LT
|
RT
|
|
SLR
|
Pain
|
|
CMT
|
LT
|
|
RT
|
Milgram's
|
|
Pain
|
CMT
|
|
LT
|
RT
|
|
Heel/Toe
|
Pain
|
|
CMT
|
LT
|
|
RT
|
Nachlas
|
|
Pain
|
CMT
|
|
LT
|
RT
|
|
Pelvic Comp
|
Pain
|
|
CMT
|
LT
|
|
RT
|
Sub-Occipital
|
|
SCM
|
Scalenes
|
|
Trapezius
|
Levator Scapula
|
|
Rhomboids
|
Supraspinatus
|
|
Infraaspinatus
|
Teres Min./Maj
|
|
Subscapularis
|
Psoas
|
|
Quad Lumb
|
Piriformis
|
|
Gluts
|
TFL/ITB
|
|
Hamstrings
|
|
|
Biceps (C5)
|
Comments
|
|
Brachio (C6)
|
Comments
|
|
Triceps (C7)
|
Comments
|
|
Patellar (L4)
|
Comments
|
|
Treatment Plan
|
|
|
CMT
|
TE
|
|
MT
|
EMS
|
|
Others
|
|
|
Posture - Head/Cervical
|
WNL
|
|
Tilt
|
EST
|
|
Translation
|
EST
|
|
Shoulder/Thor
|
WNL
|
|
Tilt
|
EST
|
|
Translation
|
EST
|
|
Pelvis/Lumbar
|
WNL
|
|
Tilt
|
EST
|
|
Translation
|
EST
|
|
Short Leg
|
WNL
|
|
Tilt
|
EST
|
|
Body Diagram
|
Re-evaluation date
|
|
Speech
|
Gait
|
|
Rhomberg's
|
Demeanor
|
|
Patient Status
|
Expected release date from this episode
|
|
Unable to determine with a high degree of med. certainty at this time
|
|
|
Will re-evaluate at next examination
|
|
|
Same as expected release date listed previously
|
|
|
Completed TX without incident
|
Comments
|
|
Patient follow-up
|
As per plan in ___ Days
|
|
in
|
PRN
|
|
continuation/completion of treatment plan ___ Re-evaluation
|
|
|
I attest that I have reviewed today's notes for today’s visit and all the services
|
|
