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Review of Systems
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General ( - )
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General
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Skin ( - )
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Skin
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Musculoskeletal ( - )
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Musculoskeletal
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Neurological ( - )
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Neurological
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Neck ( - )
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Neck
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Peripheral Vascular ( - )
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Peripheral Vascular
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Cardiovascular ( - )
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Cardiovascular
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Respiratory ( - )
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Respiratory
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Subjective
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Initial Comments
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Timing
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Onset
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Date of Onset
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Mechanism of Injury
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History of Illness
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No Other Care Before Today
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Other Doctors / Providers
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Denies Numbness/Tingling
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Numbness / Tingling
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Denies Night Sweats / Weight Loss
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Sleep
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Objective
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Observation:
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Edema / Ecchymosis / Atrophy
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Gait Cycle
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Cervical Exam
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Tender Facets
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Cervical ROM
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AROM Within Normal Limits
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Flexion
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With Pain?
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Extension
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With Pain?
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Right Rotation
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With Pain?
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Left Rotation
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With Pain?
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Right Lateral Flexion
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With Pain?
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Left Lateral Flexion
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With Pain?
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Cervical Orthopedic Tests
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Cervical Compression Test
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Cervical Distraction
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Right Max Compression
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Left Max Compression Test
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Jacksons Cervical Test
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Shoulder Depression Test
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Bakodys
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Adsons
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Valsalva
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Thoracic Exam
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Tender Facets
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Thoracic Spine Orthopedic Tests
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Schepelmann's Sign
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Spinous Percussion
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Adams Sign
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Lumbar Exam
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Tender Facets
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Lumbar AROM:
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AROM Within Normal Limits?
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Flexion
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With Pain?
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Extension
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With Pain?
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Left Rotation
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With Pain?
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Right Rotation
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With Pain?
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Left Lateral Flexion
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With Pain?
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Right Lateral Flexion
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With Pain?
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Lumbar Orthopedic Tests
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Kemps Test
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Bragards
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SLR
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Well Leg Raise
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Trendelenburg
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Yeomans
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Minors sign
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Valsalva
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Toe Walk
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Heel Walk
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SI Compression Test
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Hip Circumduction
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Neurological
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Upper Extremity Myotomes
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Myotomes Within Normal Limits?
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Left C5 (Shoulder Abduction)
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Right
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Left C6 (Elbow Flexion / Wrist Extension)
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Right
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Left C7 (Elbow Extension / Wrist Flexion)
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Right
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Left C8 (Finger Flexion)
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Right
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Left T1 (Finger Abduction)
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Right
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Light Touch
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Light Touch Within Normal Limits?
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C5
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C6
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C7
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C8
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T1
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Lower Extremity Myotomes
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Myotomes Within Normal Limits?
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Left L2/L3 (Hip Flexion)
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Right
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Left L3/4 (Knee Extension)
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Right
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Left L4/L5 (Ankle Dorsiflexion)
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Right
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Left L5 (Great Toe Extension)
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Right
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Left S1 (Ankle Dorsiflexion)
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Right
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Deep Tendon Reflexes
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DTR Within Normal Limits?
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Left C5
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Right C5
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Left C6
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Right C6
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Left C7
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Right C7
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Left L4
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Right L4
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Left S1
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Right S1
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Shoulder Exam
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Shoulder AROM
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AROM Within Normal Limits?
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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 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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Left Abduction
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Right Abduction
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Left Adduction
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Right Adduction
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Shoulder Orthopedic Tests
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Hawkin's - Kennedy
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O'Brien's Test
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Impingement Sign
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Crank Test
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Neer's test
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Bicep Load Test II
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Speeds Test
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Empty Can
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Yergason's Test
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Dawburns Test
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AC Joint Palpation
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Hyperextension Test
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Elbow / Wrist / Hand Exam
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Elbow / Wrist / Hand Orthopedic Tests
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Cozen's Test
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Reverse Cozen's Test
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Mill's Test
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Reverse Mill's Test
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Pronator Teres Syndrome Test
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Tinel's Test
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Varus Stress Test
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Valgus Stress Test
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Finklestein's Test
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Froment's Cone Test
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Median Nerve Compression Test
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Phalen's Test (median nerve)
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Elbow / Wrist / Hand AROM
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AROM Within Normal Limits?
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Left Elbow Extension
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Right Elbow Extension
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Left Elbow Flexion
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Right Elbow Flexion
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Left Forearm Pronation
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Right Forearm Pronation
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Left Forearm Supination
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Right Forearm Supination
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Left Wrist Extension
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Right Wrist Extension
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Left Wrist Flexion
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Right Wrist Flexion
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Left Unar Flexion
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Right Unar Flexion
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Left Radial Flexion
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Right Radial Flexion
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Knee / Ankle / Foot Exam
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Knee / Ankle / Foot AROM
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AROM Within Normal Limits?
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Right Knee Extension
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Left Knee Extension
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Left Knee Flexion
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Right Knee Flexion
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Left Ankle Dorsiflexion
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Right Ankle Dorsiflexion
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Left Ankle Plantar Flexion
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Right Ankle Plantar Flexion
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Left Ankle Inversion
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Right Ankle Inversion
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Left Ankle Eversion
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Right Ankle Eversion
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Knee / Ankle / Foot Orthopedic Tests
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Anterior Drawer
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Posterior Drawer
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Lachman's Test
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Apley's Compression / Distraction Test
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Varus Stress Test
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Valgus Stress Test
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Vizniak Maneuver
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Noble's Compression / Renne Test
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Achilles Squeeze Test
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Thompson's Test
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Morton's Squeeze Test
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Calcaneal Squeeze Test
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Plan
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Treatment Frequency Per Week
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Treatment Duration Weeks
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Re-examination:
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Chiropractic Adjustments
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Kinetisense 3D Movement Analysis
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Sports Medicine Modalities
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Records Reviewed
• • •
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Additional Notes
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Counseling Record (Time Override)
• • •
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Counseling Time
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