|
Initial Exam
|
Re Examination
|
|
Chief Complaint
• • •
|
% of day
• • •
|
|
Quality of pain
• • •
|
Severity of pain
• • •
|
|
Complaint 2
• • •
|
% of day
• • •
|
|
Quality of pain
• • •
|
Severity of pain
• • •
|
|
Complaint 3
• • •
|
% of day
• • •
|
|
Quality of pain
• • •
|
Severity of pain
• • •
|
|
|
|
|
Onset
|
Prior Hx of complaint
|
|
ADLs
• • •
|
Relieving Factors
• • •
|
|
ADLs Improving
|
|
|
Prior Medical
|
Prior Imaging
|
|
|
|
|
Examination
|
Re Examination Findings
|
|
Tenderness
• • •
|
Spasm/Hypertonicity
• • •
|
|
Muscle Weakness Left
• • •
|
Muscle Weakness Right
• • •
|
|
Cervical range of motion
• • •
|
Degrees
|
|
Lumbar range of motion
• • •
|
Degrees
|
|
Subluxation/Joint Fixation
• • •
|
Orthopedic Tests
• • •
|
|
Posture Analysis
• • •
|
PIRIFORMIS
|
|
DTR
|
DTR Exception
• • •
|
|
Myotomes
|
Myotome exception
• • •
|
|
Dermatomes
|
Dermatome exception
• • •
|
|
Diagnosis
|
|
|
Primary DX: Lumbago
|
Primary DX: Cervicalgia
|
|
Primary Dx: Lumbar sprain/strain
|
Primary Dx: Cervical sprain/strain
|
|
Primary DX: Lumbar Disc
|
Primary Dx: Cervical Disc
|
|
ROM Goals
• • •
|
ADL Goals
• • •
|
|
LBP Goals
|
Neck Pain Goals
• • •
|
|
|
|
|
CMT
• • •
|
Mechanical Traction
• • •
|
|
EMS
• • •
|
Therex
• • •
|
|
Manual Therapy
• • •
|
|
|
Cryotherapy
• • •
|
Moist Heat
• • •
|
|
Home Instructions
|
Treatment Schedule
• • •
|
|
Plan Of Care
• • •
|
Re Exam Tx Schedule
• • •
|
|
Doctor Signature
|
|
