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SUBJECTIVE
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Primary (1) Chief Complaint
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Primary (1) Chief Complaint
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When did the Primary (1) Chief Complaint begin?
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How did the Primary (1) Chief Complaint begin?
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Is it a new injury?
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Is the complaint getting:
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VAS Value at Best (10 being worst)
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VAS Value at Worst (10 being worst)
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What makes it better?
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What makes it worse?
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How would you describe pain/symptoms?
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How would you describe pain/symptoms?
• • •
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Does the pain/symptoms radiate anywhere?
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If yes, where do they radiate? (i.e. down arm, hand, leg, foot, around ribcage)
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Is your complaint affected by the time of day?
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If yes, how? (better or worse at the end of the day or morning)
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Secondary (2) Chief Complaint
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Secondary Chief (2) Complaint
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When did the Secondary (2) Chief Complaint begin?
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How did the Secondary (2) Chief Complaint begin?
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Is it a new injury?
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Is the complaint getting:
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VAS Value at Best (10 being worst)
/
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VAS Value at Worst (10 being worst)
/
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What makes it better?
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What makes it worse?
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How would you describe pain/symptoms?
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How would you describe pain/symptoms?
• • •
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Does the pain/symptoms radiate anywhere?
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If yes, where do they radiate? (i.e. down arm, hand, leg, foot, around ribcage)
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Is your complaint affected by the time of day?
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If yes, how? (better or worse at the end of the day or morning)
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Tertiary (3) Chief Complaint
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Tertiary (3) Chief Complaint
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When did the Tertiary (3) Chief Complaint begin?
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How did the Tertiary (3) Chief Complaint begin?
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Is it a new injury?
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Is the complaint getting:
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VAS Value at Best (10 being worst)
/
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VAS Value at Worst (10 being worst)
/
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What makes it better?
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What makes it worse?
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How would you describe pain/symptoms?
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How would you describe pain/symptoms?
• • •
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Does the pain/symptoms radiate anywhere?
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If yes, where do they radiate? (i.e. down arm, hand, leg, foot, around ribcage)
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Is your complaint affected by the time of day?
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If yes, how? (better or worse at the end of the day or morning)
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Quaternary (4) Chief Complaint
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Quaternary (4) Chief Complaint
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When did the Quaternary (4) Chief Complaint begin?
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How did the Quaternary (4) Chief Complaint begin?
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Is it a new injury?
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Is the complaint getting:
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VAS Value at Best (10 being worst)
/
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VAS Value at Worst (10 being worst)
/
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What makes it better?
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What makes it worse?
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How would you describe pain/symptoms?
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How would you describe pain/symptoms?
• • •
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Does the pain/symptoms radiate anywhere?
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If yes, where do they radiate? (i.e. down arm, hand, leg, foot, around ribcage)
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Is your complaint affected by the time of day?
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If yes, how? (better or worse at the end of the day or morning)
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Quinary (5) Chief Complaint
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Quinary (5) Chief Complaint
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When did the Quinary (5) Chief Complaint begin?
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How did the Quinary (5) Chief Complaint begin?
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Is it a new injury?
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Is the complaint getting:
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VAS Value at Best (10 being worst)
/
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VAS Value at Worst (10 being worst)
/
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What makes it better?
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What makes it worse?
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How would you describe pain/symptoms?
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How would you describe pain/symptoms?
• • •
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Does the pain/symptoms radiate anywhere?
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If yes, where do they radiate? (i.e. down arm, hand, leg, foot, around ribcage)
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Is your complaint affected by the time of day?
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If yes, how? (better or worse at the end of the day or morning)
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OBJECTIVE
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Posture Analysis
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Gait
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Range of motion
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Muscle Pain/Tenderness/Spasms
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Spinal Palpation
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Spinal Palpation Comments
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Cervical Subluxation Complex
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Thoracic Subluxation Complex
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Lumbar Subluxation Complex
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Sacroiliac Subluxation Complex
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Extremity Subluxation
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Extremity Subluxation Complex
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ASSESSMENT
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X-rays
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Comments:
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Progress
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Comments:
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Prognosis
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Comments:
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TREATMENT PERFORMED
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No Contraindications/Consent to Treat?(Required)
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Contraindications to Treatment:
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Chiropractic
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Vertebral Sublux Segments (98941)
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Spine Adj Technique used
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Extremity Adjustments 98943
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Extremity Adj Tech used
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Extremity Sublux Segments Comments
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Modalities
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Manual Therapy (97140.59)
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Location
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EMS (97014)
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Location
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EMS -UHC (G0283)
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Location
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Traction (97012)
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Duration/lbs:
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Heat /Cold pack /Ice Massage (97010)
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Location
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Therapeutic Activity/Rehab (97530.59)
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Location
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Proprioceptive Training (97530.59)
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Type of Proprioceptive Enhancement:
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Posture/Rehab Printout
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Core Stability Exercises
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Psoas Stretch form
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Other Rehab/Proprio forms/instructions:
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Strapping / Taping
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PLAN
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Chiropractic Treatment Plan
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Start and End Date of DC
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Rehab Plan
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Start and End Date of Rehab
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Re-exam (Visit #)
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Anticipated Recovery Time-frame:
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Treatment Plan-
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Functional changes
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Referrals
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Referral Comments
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Comments:
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Home Health
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Ice / Heat at home
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General Instructions
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General Instruction Comments
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Treatment Goals
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Specific ADLs
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Future Care as Needed (*DC Only)
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