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Chief Complaint
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Chief Complaint
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History of Present Illness
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Cranial Nerves Normal
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Location
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CN 1
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Quality
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CN 2
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Severity
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CN 3,4 & 6
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Duration
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CN 5
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Timing
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CN 7
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Context
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CN 8
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Medical Conditions
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CN 9 & 10
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modifying factors
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CN 11
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Subjective Neurological
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CN 12
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Assoc signs & SX
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Sensory Exam RUE
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Left Spasm/Tenderness
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Right spasm/Tenderness
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Sensory Exam LUE
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Cervical ROM restriction
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Thoracic ROM restriction
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Sensory Exam RLE
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Lumbar ROM restriction
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Extremity ROM Restriction
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Sensory Exam LLE
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Orthopedic Test
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DTR
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Patient Sign
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Normal Cervical ROM
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Muscle Test 1
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Normal Thoracic ROM
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Muscle Grade 1
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Normal Lumbar ROM
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Muscle Test 2
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Assessment:
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Muscle grade 2
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Plan: Labs
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Muscle Test 3
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Plan: Radiology
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Muscle Grade 3
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Plan: CHIRO/Physio
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Muscle Test 4
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Plan Education
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ROS
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Supplements and Protocols
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Muscle Grade 4
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Plan: Schedule
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Follow up
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Plan of medications
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Plan: Diet
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Plan: Gen Work restrict
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Constitutional
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Psychiatric
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Skin
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Endocrine
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EENT
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Allergic/Immunologic
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Cardiovascular
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Hematologic/Lymph
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Respiratory
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Urinary
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Gastrointestinal
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