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Chief complaint:
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Onset
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Comment
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Pain Scale:
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Quality of Pain
• • •
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Other
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Frequency of Pain
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Comment
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Radiation of Pain
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Comment
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Bladder/bowel symptoms
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Aggravating
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Arresting:
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Limits Daily Activities
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Limits Sports
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Comment
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Previous Occurrences
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Comment
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Previous Intervention:
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Comment
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Additional Problems
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Previous Chiropractic
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Comment
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Medications/Vitamins:
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Comment
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Hx of Cancer
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Comment
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Unexplained fever or weight loss:
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Surgeries
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Comment
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Hospitalizations
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Comment
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Family History
• • •
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Other
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Exercise:
• • •
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Comment
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Occupation
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Neck-Right Pain Scale
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Numb
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Neck-Left Pain Scale
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Numb
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Trap-Right Pain Scale
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Numb
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Trap-Left Pain Scale
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Numb
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Shoul-Right Pain Scale
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Numb
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Shoul-Left Pain Scale
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Numb
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Elbow-Right Pain Scale
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Numb
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Elbow-Left Pain Scale
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Numb
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Hand-Right Pain Scale
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Numb
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Hand-Left Pain Scale
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Numb
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Wrist-Right Pain Scale
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Numb
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Wrist-Left Pain Scale
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Numb
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Finger-Right Pain Scale
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Numb
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Finger-Left Pain Scale
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Numb
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MidBk-Right Pain Scale
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Numb
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MidBk-Left Pain Scale
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Numb
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LowBk-Right Pain Scale
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Numb
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LowBk-Left Pain Scale
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Numb
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Butt -Right Pain Scale
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Numb
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Butt -Left Pain Scale
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Numb
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Hip-Right Pain Scale
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Numb
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Hip-Left Pain Scale
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Numb
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Knee -Right Pain Scale
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Numb
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Knee-Left Pain Scale
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Numb
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Ankle-Right Pain Scale
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Numb
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Ankle-Left Pain Scale
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Numb
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Foot -Right Pain Scale
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Numb
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Foot -Left Pain Scale
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Numb
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Weakness: Right
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Weakness: Left
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Weakness: UE
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Weakness: LE
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Coldness: Right
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Coldness: Left
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Coldness: UE
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Coldness: LE
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Burning : Right
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Burning : Left
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Burning : UE
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Burning : LE
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Tingling: Right
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Tingling: Left
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Tingling: UE
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Tingling: LE
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EXAMINATION
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Vital Signs
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Height
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Weight
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Blood Pressure: Left
/
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Blood Pressure: Right
/
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Pulse
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Respiration Rate
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Temperature
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Cranial Nerves
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I Olfactory
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II Optic
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III, IV, VI
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V Trigeminal
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VII Facial
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VIII Acoustic
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IX Glossopharyngeal
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X Vagus
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XI Spinal Accessory
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XII Hypoglossal
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NECK: Range of Motion
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Flexion
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Pain
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Extension
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Pain
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Right Lateral Flexion
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Pain
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Left Lateral Flexion
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Pain
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Right Rotation
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Pain
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Left Rotation
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Pain
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Neutral Compr
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Exten Compr
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Lat Fl Compr
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Distraction
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Spurlings
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Soto Hall
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Shoulder Depression
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THORACIC: Range of Motion
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Flexion
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Pain
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Right Rotation
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Pain
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Left Rotation
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Pain
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Chest Expansion
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Pain
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Schuppelmann's N
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LUMBAR: Range of Motion
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Flexion
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Pain
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Extension
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Pain
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Right Lateral Flexion
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Pain
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Left Lateral Flexion
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Pain
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Right Rotation
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Pain
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Left Rotation
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Pain
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SLR N R
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Left
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Minor's
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Braggard's
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Double
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Bechterew's
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Exten Compr
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Valsalva
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Dejerine's
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Deep Tendon Reflexes
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Biceps: Right
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Left
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Triceps: Right
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Left
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Wrist: Right
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Left
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Patella: Right
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Left
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Hamstring/Adductor: Right
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Left
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Achilles: Right
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Left
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Babinski: Right
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Left
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Muscle Strength
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Shoulder Abduction: Right Pain
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Left
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Elbow Flexion: Right Pain
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Left
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Elbow Extension: Right Pain
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Left
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Biceps: Right
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Left Pain
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Wrist Flexion: Right Pain
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Left
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Wrist Extension: Right Pain
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Left
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Finger Flexion: Right Pain
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Left
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Finger Extension: Right Pain
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Left
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Finger Add/Abd: Right Pain
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Left
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Opposition: Right Pain
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Left
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SHOULDER: Range of Motion
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Flexion
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Pain
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Extension
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Pain
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Abduction
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Pain
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Adduction
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Pain
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Internal Rotation
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Pain
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External Rotation
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Pain
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Impingement
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Apprehension
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Yergason's
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Drop Arm
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AC Compr
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Subscap Lift
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Hornblower
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Speed's
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Winging
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ELBOW: Range of Motion
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Flexion
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Pain
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Extension
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Pain
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Pronation
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Pain
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Supination
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Pain
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Cozen's
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Mill's
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Golfer's Elbow
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Varus Stress
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Valgus Stress
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WRIST: Range of Motion
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Flexion
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Pain
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Extension
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Pain
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Radial Deviation
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Pain
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Ulnar Deviation
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Pain
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Bracelet
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Phalen's
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Allen's
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Finkelstein's
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Tinel's
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Bunnel
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Muscle Strength
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Hip Flexion: R Pain
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L Pain
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Hip Extension: R Pain
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L Pain
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Hip Internal Rotation: R Pain
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L Pain
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Hip External Rotation: R Pain
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L Pain
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Hip Abduction: R Pain
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L Pain
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Hip Adduction: R Pain
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L Pain
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Leg Flexion: R Pain
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L Pain
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Leg Extension: R Pain
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L Pain
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Foot Dorsiflexion: R Pain
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L Pain
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Foot Extension: R Pain
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L Pain
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Hallicus Extension: R Pain
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L Pain
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Hallicus Flexion: R Pain
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L Pain
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Sensation
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C4: Right
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Left
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C5: Right
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Left
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C6: Right
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Left
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C7: Right
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Left
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C8: Right
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Left
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T1: Right
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Left
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L1: Right
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Left
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L2: Right
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Left
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L3: Right
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Left
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L4: Right
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Left
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L5: Right
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Left
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S1: Right
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Left
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Grip: (lbs): Left
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Right
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Muscle Atrophy: None
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Muscle Atrophy
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GAIT
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ANTALGIA
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Heel Walk
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Toe Walk
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HIP: Range of Motion
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Flexion
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Pain
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Extension
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Pain
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Internal Rotation
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Pain
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External Rotation
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Pain
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Abduction
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Pain
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Adduction
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Pain
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Gaenslen's
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Thomas
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Fabere
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Ober's
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Hip Scouring
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Yeomans
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KNEE: Range of Motion
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Flexion
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Pain
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Extension
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Pain
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Apley's Compr
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Apley's Distr
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Valgus Stress
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Varus Stress
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AP Drawer
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Lachman's
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McMurray's
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Pivot Shift
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Pat. Ballot
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Pat Grinding
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ANKLE/FOOT: Range of Motion
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DorsiFlexion
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Pain
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Plantar Flexion
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Pain
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Inversion
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Pain
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Eversion
|
Pain
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Foot Abduction
|
Pain
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Ant.Drawer
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Talar Tilt Invers
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Thompson's
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Kleiger's
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POSTURE
|
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Pronation
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Supination
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Eversion
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Inversion
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Genu varum / valgum
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Hip Level
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Palm Rotation
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Lumbar Curve
|
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Scapular Level
|
Thoracic Curve
|
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Shoulder Level
|
Occiput Level
|
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Head Position
|
Shoulders Position
|
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Squat
• • •
|
1 leg bal.
• • •
|
