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Time In
|
|
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Reason For Referral
|
Referring Physician
|
|
HPI
|
|
|
HPI
|
|
|
PT/CHIRO
|
Injections
|
|
Pain Program/WH/WC
|
Diagnostics
|
|
Pain Assessment
|
|
|
Location
|
Duration (Const/Int)
|
|
VAS
|
Quality
• • •
|
|
Aggravation
|
Alleviation
|
|
Med Review
|
|
|
Current Meds
|
Past Meds
|
|
Allergies
|
|
|
Allergies
|
|
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PMH
|
|
|
Past Medical History
|
|
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Substance Abuse
|
Neuropsychological/Head Injury
|
|
Mental Disorder/TX
|
LMP (Date)
|
|
SURGICAL HX
|
|
|
NONE
|
Pertinent Past Surgical History
|
|
FAMILY HX
|
|
|
NONE
|
Pertinent Family Medical History
|
|
SOCIAL HX
|
|
|
Social History
|
|
|
Tobacco
|
Alcohol
|
|
Illicit Drugs
|
No Tobacco/Alcohol/Drugs
• • •
|
|
LIFESTYLE
|
|
|
Work Status
|
Ambulation/Mobility
|
|
Home Mgmt/Hygiene
|
Rec/Rest
|
|
Physical Exam
|
|
|
BP
|
Pulse
|
|
Temp
|
Weight
|
|
Height
|
|
|
Review of Systems
|
|
|
General Appearance
|
HEENT
|
|
CV
|
Pulses
|
|
Lymph Nodes
|
ABD/GU
|
|
Neuro Exam
|
|
|
Cranial Nerves
|
General Assessment
|
|
Sensory
|
|
|
Motor
|
|
|
Heel/Toe Walk
|
|
|
Reflexes
|
|
|
Biceps
|
Brachioradialis
|
|
Triceps
|
Patellar
|
|
Achilles
|
|
|
Special
|
|
|
Babinski
|
Clonus
|
|
Rhomberg
|
Heel/Shin
|
|
Finger/Nose
|
Autonomic
|
|
Orthopedic
|
|
|
SLR Supine
|
SLR Seated
|
|
Cervical/Thoracic
|
Lumbar
|
|
Upper Extremity
|
Lower Extremity
|
|
MSK Exam
|
|
|
Cervical
|
Tenderness/Spasm
|
|
ROM
|
|
|
Thoracic
|
Tenderness/Spasm
|
|
ROM
|
|
|
Lumbar
|
Tenderness/Spasm
|
|
ROM
|
|
|
Extremities
|
Findings
|
|
Diagnosis
|
|
|
Diagnosis
• • •
|
Additional Diagnosis
|
|
Recommendations
|
|
|
Chiro/PT (Traction)
• • •
|
Chiro/PT (Ultrasound)
• • •
|
|
X-rays
|
MRI/CT
|
|
Referral/Consult
|
DME
|
|
Med. Consult
|
Additional Rec
• • •
|
|
Additional Recommendations
|
|
|
Closing Statement
|
|
|
Doctor Name
|
|
|
Time In
|
|
|
Time Out
|
|
