|
Wellness care
|
No Change
|
|
Pain diagram
|
|
|
overall progress
|
(how/why)
|
|
Intensity Now
|
intensity now (comment)
|
|
Worst intensity
|
Worst intensity (comment)
|
|
% Perceived improvement
|
% perceived regression
|
|
What is better/worse
|
Other Changes
|
|
ADLs
|
ADLs (comment)
|
|
Other Pt comments
|
|
|
|
|
|
Postural abnormalities
• • •
|
|
|
Cervical AROM
• • •
|
Cervical AROM (comment)
|
|
Trunk AROM
• • •
|
Trunk AROM (comment)
|
|
cervical AROM-WNL
|
Trunk AROM WNL
|
|
|
|
|
Swtiching
• • •
|
Switching negative
|
|
Abnormal gait
|
Normal gait
|
|
|
|
|
Muscle weaknesses
|
|
|
Cervical MM
• • •
|
|
|
left upper extreamity
• • •
|
right upper extremity
• • •
|
|
left LB/lower extremity
• • •
|
right LB/lower extremity
• • •
|
|
|
|
|
Spinal listings
|
No Spine CMT
|
|
|
|
|
739.1
|
|
|
Occiput
• • •
|
C1
• • •
|
|
C2
• • •
|
C3
• • •
|
|
C4
• • •
|
C5
• • •
|
|
C6
• • •
|
C7
• • •
|
|
|
|
|
739.2
|
|
|
T1
• • •
|
T2
• • •
|
|
T3
• • •
|
T4
• • •
|
|
T5
• • •
|
T6
• • •
|
|
T7
• • •
|
T8
• • •
|
|
T9
• • •
|
T10
• • •
|
|
T11
• • •
|
T12
• • •
|
|
|
|
|
739.3
|
|
|
L1
• • •
|
L2
• • •
|
|
L3
• • •
|
L4
• • •
|
|
L5
• • •
|
Sacrum
• • •
|
|
Pelvis
• • •
|
Coccyx
• • •
|
|
Pelvic Categories
• • •
|
Crainials
• • •
|
|
739.5
|
Spinal joint play
• • •
|
|
|
|
|
Upper extremity listings
|
|
|
Left shoulder girdle
• • •
|
Right shoulder girdle
• • •
|
|
Left Elbow
• • •
|
Right Elbow
• • •
|
|
Left wrist/hand
• • •
|
Right Wrist/hand
• • •
|
|
Lower extremity listings
|
|
|
Left hip
• • •
|
Right Hip
• • •
|
|
Left knee
• • •
|
right Knee
• • •
|
|
Left ankle/foot
• • •
|
Right Ankle/foot
• • •
|
|
Extremity joint play
• • •
|
|
|
|
|
|
Tissue change 1
• • •
|
tissue 1 region
|
|
Tissue change 2
• • •
|
Tissue 2 region
|
|
Tissue change 3
• • •
|
Tissue 3 region
|
|
Tissue change 4
• • •
|
tissue 4 region
|
|
Tissue change 5
• • •
|
tissue 5 region
|
|
Tissue change 6
• • •
|
tissue 6 region
|
|
Graston
|
Graston region
|
|
MRT
|
MRT region
|
|
|
|
|
Muscle stim
|
stim region
• • •
|
|
Ultrasound/combo
|
US/combo region
• • •
|
|
traction
|
traction region
• • •
|
|
vibracussor
|
vibracussor region
• • •
|
|
other PT
• • •
|
other PT region
• • •
|
|
|
|
|
General assessment
|
General assessment (Comment)
|
|
Response to tx
|
Response to Tx (comment)
|
|
Compliance
• • •
|
Compliance (comment)
|
|
|
|
|
unequal legs
|
|
|
|
|
|
CMT 1-2
|
CMT 3-4
|
|
CMT 5-6
|
CMT extremity
|
