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Chief Complaint
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Provider report:
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NOT ON NOTE
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Secondary Complaint
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Secondary Complaint
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Patient presents with
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Pain radiates into
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Patient describes numbness and tingling into
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CURRENT reported pain
/
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Pain Frequency at this Visit
• • •
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Timing as of this Visit
• • •
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Pain Description
• • •
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Other Comments
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Examination
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Cervical Spine
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Cervical ROM
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All cervical ROM WNL
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Flexion
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Extension
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Left Rotation
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Right Rotation
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Left Lateral Bend
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Right Lateral Bend
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Other comments:
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Cervical Palpation
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Palpation (bilateral)
• • •
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Palpation (left)
• • •
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Palpation (right)
• • •
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Cervical and Thoracic Segmental Dysfunction
• • •
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Body language observed
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Other comments
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Cervical Orthopedic Tests
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All Cervical Orthopedic Testing Negative
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Cervical Compression Test
• • •
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Cervical Distratction Test
• • •
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Jackson's Foraminal Compression Test
• • •
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Maximum Cervical Compression Test
• • •
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Other Comments
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Thoracic Spine
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Thoracic ROM
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All thoracic ROM WNL
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Flexion
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Extension
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Left Rotation
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Right Rotation
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Left Lateral Bend
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Right Lateral Bend
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Other comments:
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Thoracic Palpation
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Palpation (bilateral)
• • •
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Palpation (left)
• • •
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Palpation (right)
• • •
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Cervical and Thoracic Segmental Dysfunction
• • •
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Body language observed
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Other comments
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Thoracic Orthopedic Tests
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All Thoracic Orthopedic Testing Negative
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Schepelmann's
• • •
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Lateral Rib Compression
• • •
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Inhalation (Deep Breath)
• • •
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Sternal Compression
• • •
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Other comments
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Neurological Exam Upper
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Upper Motor
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All Strength WNL
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Left C5 (Deltoid)
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Right C5 (Deltoid)
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Left C6 (Biceps & Wrist Extension)
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Right C6 (Biceps & Wrist Extension)
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Left C7 (Triceps & Wrist Flexion)
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Right C7 (Triceps & Wrist Flexion)
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Left C8 (Finger Flexion)
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Right C8 (Finger Flexion)
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Left T1 (Finger Abduction)
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Right T1 (Finger Abduction)
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Other Comments
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Upper Sensory
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All Sensory Pin Prick Testing WNL
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Left C4 (Posterior shoulder)
• • •
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Right C4 (Posterior shoulder)
• • •
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Left C5 (Lateral arm)
• • •
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Right C5 (Lateral arm)
• • •
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Left C6 (Thumb)
• • •
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Right C6 (Thumb)
• • •
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Left C7 (Middle finger)
• • •
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Right C7 (Middle finger)
• • •
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Left C8 (Pinky finger)
• • •
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Right C8 (Pinky finger)
• • •
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Other Comments
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Upper Deep Tendon Reflexes
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All DTR's WNL
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Left C5 (Biceps)
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Right C5 (Biceps)
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Left C6 (Brachioradialis)
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Right C6 (Brachioradialis)
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Left C7 (Triceps)
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Right C7 (Triceps)
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Other Comments
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Lumbar Spine
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Lumbar ROM
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All lumbar ROM WNL
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Flexion
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Extension
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Left Rotation
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Right Rotation
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Left Lateral Bend
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Right Lateral Bend
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Other comments:
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Lumbar Palpation
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Palpation (bilateral)
• • •
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Palpation (left)
• • •
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Palpation (right)
• • •
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Lumbar Segmental Dysfunction
• • •
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Pelvic Segmental Dysfunction
• • •
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Sacral Segmental Dysfunction
• • •
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Body language observed
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Other comments
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Lumbar Orthopedic Tests
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All Lumbar Orthopedic Testing Negative
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Passive Straight Leg Raise
• • •
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Active Straight Leg Raise
• • •
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Passive Well Leg Raise
• • •
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Active Well Leg Raise
• • •
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Kemp's
• • •
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Yeoman's
• • •
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Ely's
• • •
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SI Compression Test
• • •
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Other comments
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Neurological Exam Lower
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Lower Motor
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All Strength WNL
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Left L2/3 (Hip Flexion)
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Right L2/3 (Hip Flexion)
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Left L4 (Knee Extension)
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Right L4 (Knee Extension)
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Left L5 (Dorsiflexion)
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Right L5 (Dorsiflexion)
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Left S1 (Plantarflexion)
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Right S1 (Plantarflexion)
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Other comments
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Lower Sensory
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All Sensory Pin Prick Testing WNL
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Left L2 (Medial upper thigh)
• • •
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Right L2 (Medial upper thigh)
• • •
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Left L3 (Lower medial thigh)
• • •
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Right L3 (Lower medial thigh)
• • •
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Left L4 (Medial leg)
• • •
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Right L4 (Medial leg)
• • •
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Left L5 (Lateral leg)
• • •
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Right L5 (Lateral leg)
• • •
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Left S1 (Sole of foot)
• • •
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Right S1 (Sole of foot)
• • •
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Other comments
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Lower Deep Tendon Reflexes
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All DTR's WNL
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Left Patella (L2-L4)
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Right Patella (L2-L4)
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Left Achilles (S1)
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Right Achilles (S1)
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Other comments
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Hip
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Hip ROM
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All hip ROM WNL on the left
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All hip ROM WNL on the right
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Left Flexion
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Right Flexion
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Left Extension
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Right Extension
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Left Abduction
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Right Abduction
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Left Adduction
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Right Adduction
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Left Internal Rotation
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Right Internal Rotation
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Left External Rotation
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Right External Rotation
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Other Comments:
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Hip Palpation
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Palpation (bilateral)
• • •
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Palpation (left)
• • •
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Palpation (right)
• • •
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Body language observed
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Other comments:
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Hip Orthopedic Tests
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All Hip Orthopedic Testing Negative
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FABER
• • •
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FADDIR
• • •
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Ober's
• • •
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Other comments
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Shoulder
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Shoulder ROM
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All shoulder ROM WNL on the left
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All shoulder ROM WNL on the right
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Left Flexion
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Right Flexion
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Left Extension
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Right Extension
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Left Abduction
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Right Abduction
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Left Adduction
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Right Adduction
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Left Internal Rotation
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Right Internal Rotation
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Left External Rotation
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Right External Rotation
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Other comments:
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Shoulder Palpation
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Palpation (bilateral)
• • •
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Palpation (left)
• • •
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Palpation (right)
• • •
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Body language observed
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Other comments
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Shoulder Orthopedic Tests
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All Shoulder Orthopedic Testing Negative
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Empty Can
• • •
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Resisted Flexion Thumb Up
• • •
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O'Brien's
• • •
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Impingement Sign
• • •
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Dugas
• • •
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Yergason's
• • •
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Other comments
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Knee
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Knee ROM
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All knee ROM WNL on the left
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All knee ROM WNL on the right
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Left Flexion
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Right Flexion
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Left Extension
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Right Extension
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Other comments:
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Knee Palpation
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Palpation (bilateral)
• • •
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Palpation (left)
• • •
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Palpation (right)
• • •
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Body language observed
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Other comments
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Knee Orthopedic Tests
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All Knee Orthopedic Testing Negative
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Anterior Drawer (ACL)
• • •
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Posterior Drawer (PCL)
• • •
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McMurray's
• • •
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Patellar Grind
• • •
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Apley's Compression
• • •
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Apley's Distraction
• • •
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Valgus Stress
• • •
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Varus Stress
• • •
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Other comments
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Elbow and Wrist
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Elbow ROM
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All elbow ROM WNL on the left
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All elbow ROM WNL on the right
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Left Flexion
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Right Flexion
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Left Extension
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Right Extension
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Left Pronation
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Right Pronation
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Left Supination
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Right Supination
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Other comments:
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Elbow Palpation
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Palpation (bilateral)
• • •
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Palpation (left)
• • •
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Palpation (right)
• • •
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Body language observed
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Other comments
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Elbow Orthopedic Tests
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All Elbow Orthopedic Testing Negative
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Cozen's (Lat Epi)
• • •
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Reverse Cozen's (Med Epi)
• • •
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Valgus Stress (Medial Collateral Ligament)
• • •
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Varus Stress (Lateral Collateral Ligament)
• • •
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Maudsley's (Middle Finger, Lat Epi)
• • •
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Milking Maneuver (Ulnar Collateral Ligament)
• • •
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Other comments
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Wrist ROM
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All wrist ROM WNL on the left
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All wrist ROM WNL on the right
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Left Flexion
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Right Flexion
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Left Extension
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Right Extension
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Left Ulnar Deviation
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Right Ulnar Deviation
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Left Radial Deviation
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Right Radial Deviation
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Other comments:
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Wrist Palpation
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Palpation (bilateral)
• • •
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Palpation (left)
• • •
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Palpation (right)
• • •
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Other comments
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Wrist Orthopedic Tests
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All Wrist Orthopedic Testing Negative
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Finkelstein's
• • •
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Tinel's
• • •
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Table Lift Test
• • •
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Scaphoid Pain
• • •
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Other comments
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Ankle and Foot
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Ankle and Foot ROM
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All ankle ROM WNL on the left
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All ankle ROM WNL on the right
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Left Dorsiflexion
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Right Dorsiflexion
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Left Plantarflexion
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Right Plantarflexion
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Left Inversion
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Right Inversion
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Left Eversion
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Right Eversion
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Other comments:
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Ankle and Foot Palpation
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Palpation (bilateral)
• • •
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Palpation (left)
• • •
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Palpation (right)
• • •
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Body language observed
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Other comments
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Ankle and Foot Orthopedic Tests
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All Ankle/Foot Orthopedic Testing Negative
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Anterior Drawer
• • •
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Posterior Drawer
• • •
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Toe Raise
• • •
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Tinel's
• • •
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Syndesmotic High Ankle
• • •
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Morton's Neuroma
• • •
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Other comments
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Treatment and Procedures
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Evaluation Only Visit?
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Manual Therapy & Rehab
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Manual Therapy
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Cervical and Thoracic 25 minutes
• • •
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Lumbar and Hip 25 minutes
• • •
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Shoulder 25 minutes
• • •
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Knee 25 minutes
• • •
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Elbow and Wrist 25 minutes
• • •
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Foot and Ankle 25 minutes
• • •
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Other comments:
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Physitrack Active Care Rehab
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In-office Rehab Performed 30 minutes
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Modifications to Physitrack Rehab Plan?
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Physitrack Rehab Plan
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Kinesiology Tape
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Kinesiotape Applied?
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Other comments
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Icing Instructions
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Icing Instructions Given?
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Other comments
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Chiropractic Adjustment
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Adjustment/Manipulation
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Segments Adjusted
• • •
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Plan and Impression
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Tolerated Treatment Well
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Patient was instructed to minimize/limit activity
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Provider Prescribed Visits Amount
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Continues to respond favorably (Follow up only)
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Patient Prognosis
• • •
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Continue current treatment plan (Follow up only)
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Discharge from current treatment plan
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Post Visit Comments
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Cervical Spine Impression
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Thoracic Spine Impression
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Cervical and Thoracic Impression
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Lumbar Spine Impression
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Lumbar Spine & Hip Impression
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Left Hip Impression
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Right Hip Impression
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Bilateral Hip Impression
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Left Shoulder Impression
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Right Shoulder Impression
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Bilateral Shoulder Impression
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Left Knee Impression
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Right Knee Impression
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Bilateral Knee Impression
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Left Elbow Impression
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Right Elbow Impression
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Bilateral Elbow Impression
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Left Wrist Impression
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Right Wrist Impression
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Bilateral Wrists Impression
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Left Ankle/Foot Impression
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Right Ankle/Foot Impression
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Bilateral Ankle/Foot Impression
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