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Initial Evaluation/ Examination Report
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DOA
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Mechanism of Injury
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Enter Mechanism of injury
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Subjective complaints
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Neck pain
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Pain scale
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How often
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Radiates to
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Upper back pain
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Pain scale
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How often
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Radiates to
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Mid-back pain
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Pain scale
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How often
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Radiates to
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Head ache
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Pain scale
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How often
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Radiates to
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Low back pain
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Pain scale
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How often
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Radiates to
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On - To enter other body area1
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Body area
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Pain scale
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How often
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Radiates to
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On - To enter other body area2
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Body area
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Pain scale
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How often
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Radiates to
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On - To enter other body area3
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Body area
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Pain scale
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How often
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Radiates to
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On - To enter other body area4
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Body area
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Pain scale
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How often
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Radiates to
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On - To enter other body area5
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Body area
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Pain scale
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How often
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Radiates to
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Pain scale denotions
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Past Medical & Surgical history
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Past Medical History
• • •
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Past Surgical History
• • •
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Family history
• • •
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Current Medications
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Prior Injuries
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ON - If patient denies history
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Work Status
• • •
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Other work status - Please mention
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Physical examination
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Height
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Weight
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Blood pressure
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Pulse
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ON - To show patient's gender
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Hand dominant
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Clinical Photo
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Ranges of motion
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Range of motion in degrees
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Cervical
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Flexion (if normal)
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If not normal (choose one)
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Pain?
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Extension (if normal)
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If not normal (choose one)
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Pain?
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Right LAT. bend (if normal)
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If not normal (choose one)
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Pain?
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Left LAT. bend (if normal)
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If not normal (choose one)
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Pain?
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Right Rotation (if normal)
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If not normal (choose one)
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Pain?
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Left Rotation (if normal)
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If not normal (choose one)
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Pain?
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Lumbar
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Flexion (if normal)
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If not normal (choose one)
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Pain?
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Extension (if normal)
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If not normal (choose one)
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Pain?
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Right LAT. bend (if normal)
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If not normal (choose one)
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Pain?
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Left LAT. bend (if normal)
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If not normal (choose one)
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Pain?
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Right rotation (if normal)
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If not normal (choose one)
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Pain?
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Left rotation (if normal)
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If not normal (choose one)
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Pain?
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Right Shoulder
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Flexion (if normal)
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If not normal (choose one)
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Pain?
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Extension (if normal)
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If not normal (choose one)
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Pain?
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Abduction (if normal)
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If not normal (choose one)
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Pain?
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Adduction (if normal)
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If not normal (choose one)
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Pain?
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Internal rotation (if normal)
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If not normal (choose one)
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Pain?
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External rotation (if normal)
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If not normal (choose one)
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Pain?
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Left Shoulder
|
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Flexion (if normal)
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If not normal (choose one)
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Pain?
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Extension (if normal)
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If not normal (choose one)
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Pain?
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Abduction (if normal)
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If not normal (choose one)
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Pain?
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Adduction (if normal)
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If not normal (choose one)
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Pain?
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Internal rotation (if normal)
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If not normal (choose one)
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Pain?
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External rotation (if normal)
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If not normal (choose one)
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Pain?
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Right Elbow
|
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Flexion (if normal)
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If not normal (choose one)
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Pain?
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Extension (if normal)
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If not normal (choose one)
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Pain?
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Pronation (if normal)
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If not normal (choose one)
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Pain?
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Supination (if normal)
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If not normal (choose one)
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Pain?
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Left Elbow
|
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Flexion (if normal)
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If not normal (choose one)
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Pain?
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Extension (if normal)
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If not normal (choose one)
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Pain?
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Pronation (if normal)
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If not normal (choose one)
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Pain?
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Supination (if normal)
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If not normal (choose one)
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Pain?
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Right Wrist
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Flexion (if normal)
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If not normal (choose one)
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Pain?
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Extension (if normal)
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If not normal (choose one)
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Pain?
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Ulnar Deviation (if normal)
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If not normal (choose one)
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Pain?
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Radial Deviation (if normal)
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If not normal (choose one)
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Pain?
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Left Wrist
|
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Flexion (if normal)
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If not normal (choose one)
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Pain?
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Extension (if normal)
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If not normal (choose one)
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Pain?
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Ulnar Deviation (if normal)
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If not normal (choose one)
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Pain?
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Radial Deviation (if normal)
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If not normal (choose one)
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Pain?
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Right Hip
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Flexion (straight knee) (if normal)
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If not normal (choose one)
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Pain?
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Extension (bent knee) (if normal)
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If not normal (choose one)
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Pain?
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Adduction (if normal)
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If not normal (choose one)
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Pain?
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Abduction (if normal)
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If not normal (choose one)
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Pain?
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Left Hip
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Flexion (straight knee) (if normal)
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If not normal (choose one)
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Pain?
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Extension (bent knee) (if normal)
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If not normal (choose one)
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Pain?
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Adduction (if normal)
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If not normal (choose one)
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Pain?
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Abduction (if normal)
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If not normal (choose one)
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Pain?
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Right Knee
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Flexion (if normal)
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If not normal (choose one)
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Pain?
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Extension (if normal)
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If not normal (choose one)
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Pain?
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Left Knee
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Flexion (if normal)
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If not normal (choose one)
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Pain?
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Extension (if normal)
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If not normal (choose one)
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Pain?
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Right Ankle
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Plantarflexion (if normal)
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If not normal (choose one)
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Pain?
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Dorsiflexion (if normal)
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If not normal (choose one)
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Pain?
|
|
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Inversion (if normal)
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If not normal (choose one)
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Pain?
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Eversion (if normal)
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If not normal (choose one)
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Pain?
|
|
|
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|
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Left Ankle
|
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Plantarflexion (if normal)
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If not normal (choose one)
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Pain?
|
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Dorsiflexion (if normal)
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If not normal (choose one)
|
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Pain?
|
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Inversion (if normal)
|
If not normal (choose one)
|
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Pain?
|
|
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Eversion (if normal)
|
If not normal (choose one)
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Pain?
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ON - if orthopedic evaluation NOT performed
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ON - if orthopedic evaluation performed
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Max Cervical Compression
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Postive or Negative?
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Area
• • •
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Radiates to
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Jackson's Compression
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Postive or Negative?
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Area
• • •
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Radiates to
|
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Cervical distraction
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Postive or Negative?
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Area
• • •
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Radiates to
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Soto Hall's
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Postive or Negative?
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Area
• • •
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Radiates to
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Shoulder depression
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Postive or Negative?
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Area
• • •
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Radiates to
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Kemp's
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Postive or Negative?
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Area
• • •
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Radiates to
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Laseque's
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Postive or Negative?
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Area
• • •
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Radiates to
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Braggard's
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Postive or Negative?
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Area
• • •
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Radiates to
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Ely's
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Postive or Negative?
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Area
• • •
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Radiates to
|
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Hibb's
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Postive or Negative?
|
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Area
• • •
|
Radiates to
|
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Valsalva's
|
Postive or Negative?
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Area
• • •
|
Radiates to
|
|
Other orthopedic tests (please specify)
|
Other orthopedic tests (please specify)
|
|
Other orthopedic tests (please specify)
|
Other orthopedic tests (please specify)
|
|
Other orthopedic tests (please specify)
|
Other orthopedic tests (please specify)
|
|
Neurological Evaluation
|
|
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Deep Tendon Reflexes
|
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Biceps (C5) - Right
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Biceps (C5) - Left
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Triceps (C6) - Right
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Triceps (C6) - Left
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Brachioradialis (C7) - Right
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Brachioradialis (C7) - Left
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Patella (L5) - Right
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Patella (L5) - Left
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Achilles (S1) - Right
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Achilles (S1) - Left
|
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Dermatomes
|
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C5 R
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C5 L
|
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C6 R
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C6 L
|
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C7 R
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C7 L
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C8 R
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C8 L
|
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T1 R
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T1 L
|
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L2 R
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L2 L
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L3 R
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L3 L
|
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L4 R
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L4 L
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L5 R
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L5 L
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S1 R
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S1 L
|
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Cranial Nerves (select the performed tests
|
|
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Cr 1 (olfactory) - Choose positive or negative
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Cr 1 (olfactory) - Description
|
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Cr 2 (optic) - Choose positive or negative
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Cr 2 (optic) - Description
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Cr 3,4,6 - Choose postivie or negative
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Cr 3,4,6 (oculomotor, trochlear and abducens) - Description
|
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Cr 5 (trigeminal) - Choose positive or negative
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Cr 5 (trigeminal) - Description
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Cr 7 (facial) - Choose postivie or negative
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Cr 7 (facial) - Description
|
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Cr 8 (vestibulocochlear) - Choose postivie or negative
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Cr 8 (vestibulocochlear) - Description
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Cr 9 and 10 - Choose positive or negative
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Cr 9 and 10 (glossopharyngeal, vagus) - Description
|
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Cr 11 (accessory) - Choose positive or negative
|
Cr 11 (accessory) - Description
|
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Cr 12 (hypoglossal) - Choose postivie or negative
|
Cr 12 (hypoglossal) - Description
|
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Musculoskeletal examination
|
|
|
Inspection of cervical spine
|
With patient in upright position - Description
|
|
Palpation
|
|
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Cervical
• • •
|
Thoracic
• • •
|
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Lumbo-Sacral
• • •
|
Additional palpation findings
|
|
Muscle groups - hypertonicity was found
• • •
|
Muscle groups - Active trigger points located
• • •
|
|
Rivermead Post-Concussion symptoms questionnaire
|
|
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Initial Assessment/ Diagnosis
|
|
|
Driver injured in collision (V49.40XA)
|
Passenger injured in collision (V49.50XA)
|
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Dislocation of unspecified cervical vertebrae
|
Dislocation of unspecified thoracic vertebrae (S33.101A)
|
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Dislocation of unspecified lumbar vertebrae (S23.101A)
|
Segmental and somatic dysfunction (M99.01)
|
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Segmental and somatic dysfunction (M99.02)
|
Segmental and somatic dysfunction (M99.03)
|
|
Segmental and somatic dysfunction (M99.04)
|
Sprain of ligaments of cervical spine (S13.4XXA)
|
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Sprain of ligaments of thoracic spine (S23.3XXA)
|
Sprain of ligaments of lumbar spine (S33.5XXA)
|
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Sprain of ligaments of sacrum spine (S33.8XXA)
|
Cervical disc displacement (M50.20)
|
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Thoracic disc displacement, (M51.24)
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lumbar disc displacement (M51.26)
|
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Disorder of ligament (M24.20)
|
Lordosis loss, unspecified, site unspecified (M40.50)
|
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other kyphosis, site unspecified (M40.299)
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Unspecified disturbances of skin sensation (R20.9)
|
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Contracture of muscle (M62.40)
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Headache (R51)
|
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Tension type headache (G44.209)
|
Sleep disorder, unspecified (G47.9)
|
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Dizziness/ giddiness (R42)
|
Unspecified superficial injury (S00.90XA)
|
|
Concussion with loss of consciousness (S06.0X1A)
|
Post concussional syndrome (F07.81)
|
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Acute stress reaction (F43.0)
|
Temporomandibular joint disorder (M26.60)
|
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Difficulty in walking (R26.2)
|
Spinal enthesopathy (M46.00)
|
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Cervicalgia (M54.2)
|
Thoracalgia (M54.6)
|
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Lumbago (M54.5)
|
Chest pain (R07.9)
|
|
Sprain of ligaments of shoulder joint (S43.409A)
|
Sprain of ligaments of elbow (S53.409A)
|
|
Sprain of ligaments of wrist (S63.409A)
|
Sprain of ligaments of hand (S63.90XA)
|
|
Sprain of ligaments of hip (S73.109A)
|
Sprain of ligaments of knee (S83.409A)
|
|
Sprain of ligaments of ankle (S83.90XA)
|
Additional diagnosis
|
|
Additional diagnosis
|
Additional diagnosis
|
|
Additional diagnosis
|
|
|
Initial Treatment
|
|
|
New patient evaluation
|
Mechanical Traction
|
|
Electrical Stimulation
|
Chiropractic Adjustment
|
|
Cryotherapy
|
Massage
|
|
Therapeutic Exercises
|
Neuromuscular Re-education
|
|
Therapeutic Activities
|
Self care/ Home management training
|
|
Work integration training
|
Other treatments (please specify)
|
|
Other treatments (please specify)
|
|
|
Initial Recommendations
|
|
|
No. of time(s) to be treated (in numbers)
|
Treatment per week or month?
|
|
Number of weeks for re-evaluation
|
No. of visits to determine future treatment
|
|
Recommended treatment
|
|
|
Chiropractic manipulation
|
Manual therapy
|
|
Traction (axial)
|
Flexion/ Disraction traction
|
|
Halo Traction
|
Hot or Cold pack
|
|
Electrical stimulation
|
Therapeutic ex/ neuromuscular re-education
|
|
Therapeutic activity
|
Massage
|
|
TENS/ Supplies
|
LSO
|
|
Conductive garment
|
Brace
|
|
Vitamin and mineral supplementation
|
Cervical pillow/ collar
|
|
Lenzagel, Medrox Patch/Gel
|
Self care/ home management training
|
|
Active home care
|
Work reintegration training
|
|
Additional recommended treatments (please specify)
|
Additional recommended treatments (please specify)
|
|
Additional recommended treatments (please specify)
|
|
|
Recommended Referrals
|
|
|
Referred to medical provider for evaluation
|
Specify doctor's name if needed
|
|
Patient was seen at hospital
|
Hospital name
|
|
Referred to this facility by a med provider
|
Name of med provider
|
|
Patient will be referred to a med specialist
|
Name of medical specialist
|
|
Recommended diagnostic referral
|
|
|
MRI and/or EMG/NCV will be considered
|
|
|
MRI
|
Description
|
|
XRAY
|
Description
|
|
Others (please specify)
|
|
|
Recommended Work Status
|
Functional loss/ ADLs
|
|
Causation 1 - No contributing factors
|
Mention work related accident
|
|
Causation 2 - may have contributing factors
|
Mention work related accident
|
|
Prior Subsequent Injury
|
Additional info
|
|
Prognosis
|
|
|
No. weeks to complete symptomatic relief
|
Likelihood to complete symptomatic relief is ___
|
|
Should reach chiro/phy relief improvement____ months
|
Patient's prognosis is ____
|
|
Ligamentous Laxity, Cervical, Thoracic, Lumbar Regions
|
|
|
Delay in seeking care
|
Mention any Additional treatments
|
|
Discussion
|
Mention work related accident
|
|
Permanent Disability Factors to Consider
|
|
|
Closing statement
|
|
|
Attending physician
|
|
|
Disclosure statement
|
|
|
Exhibit Listings
|
|
|
Harrison DD, Jackson BI, Troyanovich SJ, Robertson GA, DeGeorge D, Barker WF
|
Harrison DE, CAilliet R, Harrison DD, Troyanovich SJ, Harrison SO (Part II)
|
|
Harrison DE, CAilliet R, Harrison DD, Troyanovich SJ, Harrison SO (Part III)
|
International Chiropractors Association
|
|
Ligamentous instability
|
Female gender
|
|
Immediate/early onset of symptoms
|
Initial back pain
|
|
Use of seat belt/shoulder harness
|
Initial Phvsical finding of limited range of motion
|
|
Neck pain on palpation, and muscle pain
|
Headache
|
|
Initial neurological symptoms; radiating pain into upper extremities
|
Loss or reversal of cervical lordosis
|
|
Front seat position
|
88% of whiplash victims will have pain 10.8 years later
|
|
Ferrantelli J, Harrison DE, Harrison DO, Steward D
|
Troyanovich SJ, Harrison DE, Harrison DD
|
|
Harrson DE, Cailliet R, Harrison DD, Troyanovich SJ, Harrison SO
|
Cocchiarella Linda, and Gunnar BJ. Andersson
|
|
Croft AC, Whiplash in Hyper text
|
|
