|
Subjective
|
date of last exam
|
|
Billable ReExam
|
|
|
Re Exam -
|
Corona Questionaire
|
|
Initial/Re Exam/Release
• • •
|
Attn: Dr.
|
|
Date of Auto Accident:
|
Auto Accident
|
|
Chief Complaint
• • •
|
Pain Scale
|
|
Quality of pain
• • •
|
Aggravating Factors
• • •
|
|
Palliative Factors
• • •
|
Mechanism of Injury
|
|
CC status
|
Date of Onset
|
|
Freq of Sx's
|
Inteference Rating
|
|
|
Subjective Free Text
|
|
Cigna
|
|
|
Height, Weight, BP
|
Conditions Noted within Health History
|
|
Objective
|
|
|
Postural Analysis
• • •
|
Medicare Restrictions
• • •
|
|
Region 1
|
|
|
Palpation/Spasm/Tissue Changes 1
• • •
|
Anatomy 1
• • •
|
|
Severity 1
|
Progress 1
|
|
Region 2
|
|
|
Palpation/Spasm/Tissue Changes 2
• • •
|
Anatomy 2
• • •
|
|
Severity 2
|
Progress 2
|
|
Region 3
|
|
|
Palpation/Spasm/Tissue Changes 3
• • •
|
Anatomy 3
• • •
|
|
Severity 3
|
Progress 3
|
|
Ortho/Neuro/Rom
|
|
|
Positive Orthopedic Tests
• • •
|
Other Orthopedic Comments
|
|
Neuro Exam/ROS
• • •
|
Other Neuro Comments
|
|
ROM
• • •
|
Severity, Plane
• • •
|
|
ROM 2
• • •
|
Severity, Plane 2
• • •
|
|
ROM 3
• • •
|
Severity, Plane 3
• • •
|
|
Plan
|
|
|
Treatment Schedule
• • •
|
Home Care Recommendations
• • •
|
|
Short/Long Term Goals
• • •
|
Achieved Goals
• • •
|
|
Risk Factors
• • •
|
Prognosis
|
|
|
Additional Goals
|
|
Services Performed
• • •
|
|
|
Chiro Manip
|
Trigg Pt Therapy
|
|
15 min Therapeutic Exercise
|
30 Min Therapeutic Exercise
|
|
Elec Stim
|
Ultrasound Therapy
|
|
Intersegment Trac
|
Cervical Decomp
|
|
Hot/Cold
|
Lumbar Decomp
|
|
Therapeutic Exercises Performed
• • •
|
Ther Ex Free Text
|
|
|
|
|
Referral
|
|
