|
Age / sex
|
Accident/ Injury Date
|
|
Pregnant?
|
Workers Comp date?
|
|
Chief Complaint
• • •
|
|
|
Onset date?
|
CC status
|
|
% of day?
|
|
|
Radiate?
|
Severity of pain
|
|
If yes, Where?
|
Quality of pain
• • •
|
|
Aggrevating Factors
• • •
|
Inc/Dec/Same
|
|
Relieving Factors
• • •
|
Symp. worst when?
|
|
Other Symptoms
• • •
|
|
|
|
|
|
OBJ CC
• • •
|
Bilateral SHT
|
|
CC with
• • •
|
L SHT
|
|
Trap Fibers
• • •
|
R SHT
|
|
R Spasm and Tenderness
• • •
|
Arm Fossa Test
• • •
|
|
L Spasm and Tenderness
• • •
|
AF negative ALL
|
|
Cranial ROM
• • •
|
Crest Sign
|
|
Cranial Adjustment
|
Dollar Sign
|
|
Positive ORTHO tests
|
Prone Short Leg
|
|
Cervical Comp. Test
|
Supine Short Leg
|
|
Records reviewed
• • •
|
Posture Analysis
• • •
|
|
Wadell Sign
|
|
|
|
|
|
Spinal Palp
• • •
|
|
|
Spinal Palp WNL
|
|
|
Cranial WNL
|
|
|
|
|
|
Occiput
• • •
|
|
|
C1
• • •
|
T1
• • •
|
|
C2
• • •
|
T2
• • •
|
|
C3
• • •
|
T3
• • •
|
|
C4
• • •
|
T4
• • •
|
|
C5
• • •
|
T5
• • •
|
|
C6
• • •
|
T6
• • •
|
|
C7
• • •
|
T7
• • •
|
|
|
T8
• • •
|
|
|
T9
• • •
|
|
|
T10
• • •
|
|
|
T11
• • •
|
|
|
T12
• • •
|
|
|
|
|
L1
• • •
|
|
|
L2
• • •
|
|
|
L3
• • •
|
|
|
L4
• • •
|
|
|
L5
• • •
|
|
|
|
|
|
Left Ilium
• • •
|
Sacrum
• • •
|
|
Right Ilium
• • •
|
Pubes
• • •
|
|
|
|
|
Category 1
|
C.R.I.
|
|
Category 2
|
Basic 1
|
|
Category 3
|
Basic 2
|
|
|
Basic 3
|
|
Occ Fiber Line 1
• • •
|
|
|
Occ Fiber Line 2
• • •
|
Chiro. First Aid
• • •
|
|
Occ Fiber Line 3
• • •
|
Posture Printout
|
|
|
Coreman Plank Printout
|
|
CMRT
• • •
|
|
|
|
|
|
PSOAS
|
|
|
Psoas Stretch form
|
|
|
PIRIFORMIS
|
|
