|
Visit Number
|
Chief Complaint
• • •
|
|
Radiating Pain
• • •
|
percent of day
|
|
Quality of pain
• • •
|
Severity
|
|
Subluxations
|
Cervical subluxations
• • •
|
|
Thoracic Subluxations
• • •
|
Lumbar Subluxations
• • •
|
|
Extraspinal Subluxations
• • •
|
Muscle Spasm
• • •
|
|
Spinal Manipulation (1-2 regions)
|
Spinal Manipulation (3-4 regions)
|
|
Extraspinal
|
Range of motion
|
|
Electric Stimulation
|
Myofascial Release
• • •
|
|
Assessment
|
Treatment Schedule
|
|
Assessment Note
|
Plan Note
|
|
DME
• • •
|
Myofacscial Release
|
|
Referral
• • •
|
SAM PRO 2.0
|
|
Discharge Summary
|
Doctor Signature
|
