|
REASON FOR APPT
• • •
|
|
|
CHIEF COMPLAINT
• • •
|
COMMENTS
|
|
CURRENT PAIN LEVEL
/
|
COMMENTS
|
|
New Yes / No
|
COMMENTS
|
|
CURRENT PAIN LEVEL (X/10)
|
COMMENTS
|
|
LAST DOSE OF MEDICATION:
• • •
|
COMMENTS
|
|
SIDE EFFECTS
• • •
|
COMMENTS
|
|
0-100% PAIN RELIEF
|
COMMENTS
|
|
History of the Present Illness
|
|
|
|
|
|
|
|
|
Physical Exam
|
|
|
General Exam
• • •
|
COMMENTS
|
|
AFFECT
• • •
|
COMMENTS
|
|
SPEECH
• • •
|
COMMENTS
|
|
NECK EXAM
• • •
|
NECK EXAM Comments
|
|
BACK EXAM
• • •
|
BACK EXAM Comments
|
|
KNEE EXAM
• • •
|
COMMENTS
|
|
SHOULDER EXAM
• • •
|
COMMENTS
|
|
ABDOMINAL EXAM
• • •
|
COMMENTS
|
|
OTHER EXAM
• • •
|
|
|
Cardiovascular WNL
|
Cardiovascular Abnormal
• • •
|
|
Cardiovascular Comments
|
|
|
Lungs WNL
|
Lungs Abnormal
• • •
|
|
Lungs Comments
|
|
|
|
|
|
|
|
|
Lymph WNL
|
Lymph Abnormal
• • •
|
|
Lymph Comments
|
|
|
Neuro WNL
|
Neuro Abnormal
• • •
|
|
Neuro Comments
|
|
|
EXTREMITIES
• • •
|
Extrem Comments
|
|
|
|
|
GAIT
• • •
|
|
|
Physical - Back Pain
|
Back Pain - Appearance
• • •
|
|
Abnormality Comments
|
|
|
Palpation
• • •
|
|
|
AROM- fwd flex (75 deg)
|
AROM- hyper ext (20 deg)
|
|
AROM- lat flex (20-30 deg)
|
AROM- rotation (40 deg)
|
|
Motor testing of all muscle groups
/
|
Deep tendon reflexes
• • •
|
|
PDMP REVIEW
• • •
|
COMMENTS
|
|
UDS
• • •
|
COMMENTS
|
|
IMAGING & OTHER STUDIES
|
|
|
ASSESSMENT
|
|
|
PLAN
• • •
|
|
|
COMMENTS
|
|
|
COMMENTS
|
|
