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SUBJECTIVE
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Patient Story (SUBJ)
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(WARNINGS):
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(MECHANISM OF INJURY / ONSET)
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(CONFIDENTIAL INFO)
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(CONFIDENTIAL MEDICAL INFO)
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Pain Locations
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Complaint #1
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Pain ( 0 = No pain, 10 = worst imaginable pain)
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Complaint #2
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Pain ( 0 = No pain, 10 = worst imaginable pain)
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Complaint #3
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Pain ( 0 = No pain, 10 = worst imaginable pain)
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Complaint #4
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Pain ( 0 = No pain, 10 = worst imaginable pain)
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OBJECTIVE
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Objective Free-Type
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Posture Analysis
• • •
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Spinal palpation
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Occiput
• • •
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C1
• • •
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C2
• • •
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C3
• • •
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C4
• • •
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C5
• • •
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C6
• • •
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C7
• • •
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T1
• • •
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T2
• • •
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T3
• • •
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T4
• • •
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T5
• • •
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T6
• • •
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T7
• • •
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T8
• • •
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T9
• • •
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T10
• • •
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T11
• • •
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T12
• • •
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L1
• • •
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L2
• • •
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L3
• • •
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L4
• • •
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L5
• • •
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Sacrum
• • •
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Pelvis
• • •
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Extremity Palpation
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Extremity Palpation
• • •
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Objective comments:
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ASSESSMENT
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Progress
• • •
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Prognosis
• • •
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Comments:
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TREATMENT PERFORMED
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Chiropractic
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Examination
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X-rays
• • •
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Spine Adj Tech used
• • •
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Extremity Adjustments 98943
• • •
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Extremity Adj Tech used
• • •
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Modalities
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EMS (97014)
• • •
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Location
• • •
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EMS (UHC) G0283
• • •
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Location
• • •
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Heat / Cold pack applied
• • •
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IASTM 97140
• • •
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Ultrasound Therapy 97035
• • •
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LMT
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Massage Therapy 97124 (59)
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Manual Therapy 97140 (59)
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Rehab
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Rehab exam
• • •
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Rehab / Stretches 97110 (59)
• • •
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(Date, Minutes, EMS?)
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Comments:
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PLAN
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Chiropractic Treatment Plan
• • •
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Start and End Date of DC
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LMT Plan
• • •
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Start and End Date of Massage
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Rehab Plan
• • •
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Start and End Date of Rehab
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Referrals
• • •
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Referral Free-Type
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Comments:
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DME / Lifts / Supplements
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Supplements / Topicals Given
• • •
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Heel Lifts Worn
• • •
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DME
• • •
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At Home Recommendations
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Home Health
• • •
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Ice / Heat at home
• • •
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General Instructions
• • •
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General Instruction Comments
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