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New Patient
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Chief Complaint
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Chief Complaint
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Comments
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History of Present Illness
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History of Present Illness
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Past Medical History
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Past Medical History
• • •
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Past Medical History Freewrite
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Past Surgical History
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Past Surgical History
• • •
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PSH Spine
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Medications
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Medications
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Comments
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Allergies
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Allergies
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Allergies
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Social History
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Comments
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Marital Status
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Living Arrangements
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Occupation
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Alcohol
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Tobacco
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REVIEW OF SYSTEMS
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ROS: Within Normal Limits
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ROS: Constitutional
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ROS: As Indicated on Intake Sheet
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ROS: HEENT
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ROS: As Indicated Below
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ROS: Endocrinologic
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ROS: Gastrointestinal
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ROS: Genitourinary
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ROS: Integumentary
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ROS: Cardiovascular
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ROS: Respiratory
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ROS: Musculoskeletal
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ROS: Hematologic/Immunologic
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ROS: Psychiatric
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ROS: Neurologic
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General Abnormal
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PHYSICAL EXAM
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Height/Weight/Vitals
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General WNL
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General Comments
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HEENT WNL
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HEENT Abnormal
• • •
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HEENT Comments
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Skin WNL
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Skin Lesion
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Skin Comments
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Cardiovascular WNL
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Cardiovascular Abnormal
• • •
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Cardiovascular Comments
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Lungs WNL
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Lungs Abnormal
• • •
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Lungs Comments
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Abdomen WNL
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Abdomen Abnormal
• • •
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Abdomen Comments
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Pulses - normal
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Pulses Abnormal
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Lymph Exam - Normal
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MSK WNL
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MSK Abnormal
• • •
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MSK Comments
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Cervical Exam - Normal
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Cervical Spine Comments
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Lumbar Spine - Normal
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Lumbar Spine Comments
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Neurological Exam - Motor Normal
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Motor Exam comments
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Neurological Exam - As Listed Below
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Neurological exam Comments
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Right Deltoid Grade
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Left Deltoid Grade
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Right Biceps Grade
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Left Biceps Grade
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Right Triceps Grade
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Left Triceps Grade
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Right Wrist Extensor Grade
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Left Wrist Extensor Grade
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RIght Wrist Flexor Grade
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Left Wrist Flexor Grade
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Right Grip Grade
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Left Grip Grade
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Right Intrinsics Grade
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Left Intrinsics Grade
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Right Iliopsoas Grade
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Left Iliopsoas Grade
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Right Quadriceps Grade
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Left Quadriceps Grade
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Right Tibialis Anterior Grade
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Left Tibialis Anterior Grade
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Right EHL Grade
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Left EHL Grade
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Right Gastrocnemius Grade
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Left Gastrocnemius Grade
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Right Peroneal Grade
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Left Peroneal Grade
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Reflexes normal
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Reflexes Abnormal
• • •
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Coordination-Normal
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Coordination comments
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Gait normal
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Gait comments
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Sensory Exam normal
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Sensory Exam comments
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Sensory Exam As Indicated Below
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Sensory Exam RUE
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Sensory Exam LUE
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Sensory Exam RLE
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Sensory Exam LLE
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Peripheral Nerve Signs
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Radicular Signs
• • •
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Myelopathic Signs
• • •
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Other pertinent exam findings
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Imaging
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XR
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CT Scan
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MRI
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Labs/Other Studies
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ASSESSMENT
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ASSESSMENT (Comments)
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PLAN:
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PLAN: Physical Therapy
• • •
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PLAN: Labs
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PLAN: Radiology
• • •
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PLAN: Neurodiagnostics
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PLAN: Referrals
• • •
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PLAN: General Instructions
• • •
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ACDF
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Cervical Posterior Decompression and Fusion
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Laminoplasty
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XLIF
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Lumbar Disecectomy
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Lumbar Decompression
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Lumbar Posterior Fusion
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ALIF
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Lumbar Decomrpression/PSF
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BMP
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FOLLOW-UP
• • •
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Total time spent
• • •
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SALUTATION
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Salutation - Melikian
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Salutation - Khurana
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