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Office Visit
• • •
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Chief Complaint
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Chief Complaint Comments
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Office Visit Comments
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ROM WNL
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Skin Inspection Comments
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CC status
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CC Status Comments
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% of day?
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% of the day Comments
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Pain Rating
• • •
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Quality of Pain Comments
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Quality of pain
• • •
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Relieving Factors Comments
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Palliative
• • •
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Palliative Factors Comments
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Provocative
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Provocative Factors Comment
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Records reviewed
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Spinal Palpation Listings
• • •
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Spinal Palpation Comments
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Muscle Pain/Tenderness/Spasms
• • •
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Posture Analysis
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Gait
• • •
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Subluxation Complex
• • •
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Pregnant/Websters
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Spinal Palp WNL
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Range of motion
• • •
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Derifield Leg Check
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Thoracic Subluxation Complex
• • •
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Cervical Subluxation Complex
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Lumbar Subluxation Complex
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T1
• • •
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Occiput
• • •
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T2
• • •
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C1
• • •
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T3
• • •
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C2
• • •
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T4
• • •
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C3
• • •
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T5
• • •
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C4
• • •
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T6
• • •
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C5
• • •
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T7
• • •
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C6
• • •
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T8
• • •
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C7
• • •
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T9
• • •
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T10
• • •
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L1
• • •
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T11
• • •
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L2
• • •
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T12
• • •
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L3
• • •
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L4
• • •
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Right Ilium
• • •
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L5
• • •
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Left Ilium
• • •
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Sacrum
• • •
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Function
• • •
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PIRIFORMIS
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Treated by:
• • •
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Response to Care
• • •
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Referrals
• • •
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Plan-at home
• • •
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Treatment Frequency
• • •
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Psoas Stretch form
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Treatment Schedule
• • •
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Core Stability Exercises
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Wellness Adjustment
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Corrective Exerice Printout
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Ice
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Electrical Stim Unattended G0283
• • •
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Cold/Hot Pack 97010
• • •
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Manual Therapy Techniques 97140
• • •
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Cervical Traction 97012
• • •
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Mechanical Traction 97012
• • •
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Therapeutic Exercise 97110
• • •
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Chiropractic Adjustments 98940
• • •
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Chiropractic Adjustments 98941
• • •
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Chiropractic Adjustments 98942
• • •
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Extraspinal Adjustments 98943
• • •
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Therapeutic Activity 97530
• • •
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Neuromuscular Re-Ed 97112
• • •
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Gait Training
• • •
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Supplies
• • •
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Daily Living Activities 97535
• • •
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Acupuncture
• • •
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Strapping or Taping
• • •
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Physical Performance Testing 97750
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Body Diagram
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Spinal Diagram
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