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Physical Examination
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Telemedicine:
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Normal General Exam
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Abnormal General Exam (fill each section)
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Constitutional
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Comments on Constitutional
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HEENT
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Comments on HEENT
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Neck
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Comments on neck
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Cardiovascular
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Comments on Cardiovascular
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Respiratory
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Comments on Respiratory
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Gastrointestinal
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Comments on Gastrointestinal
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Skin
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Comments on Skin
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Psychiatric
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Comments on Psychiatric
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Gait
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Comments on Gait
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Extermities
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Comments on extremities
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Neurologic
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Comments on Neurologic
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Sensory: select dermatomes tested
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Sensory: list abnormal areas (leave blank if all are normal)
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Motor: select myotomes tested
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Motor: list abnormal findings (leave blank if all are normal)
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Reflexes: grading scale
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Reflexes tested
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Reflexes: list abnormal reflexes (leave blank if all are normal)
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MSK Exam - Special Tests
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Cervical Exam
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Inspection
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Palpation
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Range of Motion
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Special Tests
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Cervical Exam Additional Comments (optional)
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Thoracic Exam
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Inspection
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Palpation
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Special Tests
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Thoracic Exam Additional Comments (optional)
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Lumbar Exam
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Inspection
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Palpation
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Range of Motion
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Special Tests
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Lumbar Exam Additional Comments (optional)
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Chest Wall
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Inspection
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Palpation
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Chest walll Exam Additional Comments (optional)
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Shoulder Exam
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Inspection
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Palpation
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Range of Motion
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Special Tests
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Shoulder Exam Additional Comments (optional)
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Upper Arm
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Inspection
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Palpation
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Range of Motion
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Special Tests
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Upper Arm Exam Additional Comments (optional)
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Elbow Exam
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Inspection
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Palpation
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Range of Motion
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Special Tests
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Elbow Exam Additional Comments (optional)
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Forearm
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Inspection
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Palpation
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Range of Motion
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Special Tests
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Forearm Exam Additional Comments (optional)
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Hand and Wrist Exam
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Inspection
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Palpation
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Range of Motion
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Special Tests
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Hand and Wrist Exam Additional Comments (optional)
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Hip Exam
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Inspection
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Palpation
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Range of Motion
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Special Tests
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Hip Exam Additional Comments (optional)
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Upper leg Exam
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Inspection
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Palpation
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Range of Motion
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Upper leg Exam Additional Comments (optional)
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Knee Exam
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Inspection
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Palpation
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Range of Motion
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Special Tests
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Knee Exam Additional Comments (optional)
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Lower Leg
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Inspection
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Palpation
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Range of Motion
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Special Tests
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Lower Leg Exam Additional Comments (optional)
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Foot and Ankle Exam
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Inspection
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Palpation
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Range of Motion
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Special Tests
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Foot and Ankle Exam Additional Comments (optional)
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Neurological
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Special Tests
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King-Devick Score
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Diagnostic Tests
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Any diagnostic/imaging studies reviewed with patient today?
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Imaging reviewed, 1st
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Type of imaging study, 1st
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Body region imaged, 1st
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Date of Imaging, 1st
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Significant Findings, 1st
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Imaging reviewed, 2nd
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Type of imaging study, 2nd
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Body region imaged, 2nd
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Date of Imaging, 2nd
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Significant Findings, 2nd
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Imaging reviewed, 3rd
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Type of imaging study, 3rd
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Body region imaged, 3rd
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Date of Imaging, 3rd
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Significant Findings, 3rd
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Imaging reviewed, 4th
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Type of imaging study, 4th
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Body region imaged, 4th
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Date of Imaging, 4th
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Significant Findings, 4th
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Comments on Additional Diagnostic Tests (optional)
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New Free Draw
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New Free Draw
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New Free Draw
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New Free Draw
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New Free Draw
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New Free Draw
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New Free Draw
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New Free Draw
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