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SUBJECTIVE:
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Pertinent Health History
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P: Pain/Tenderness
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CC#1:
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Pain _____/10
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Radiating pain
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Frequency _____/100%
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CC#2:
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CC#2: Pain _____/10
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Radiating pain
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Frequency _____/100%
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CC #3:
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CC#3: Pain _____/10
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Radiating pain
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Frequency _____/100%
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CC#4
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CC#4 Pain _____/10
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Radiating pain
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Frequency _____/100%
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CC#5
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CC#5 Pain _____/10
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Radiating pain
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Frequency _____/100%
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Symptoms
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Comments
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Activities
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Comments
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Home Care
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Comments
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Activities of daily living
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Activities of Daily Living
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OBJECTIVE: Patient findings
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A: Asymmetry/Misalignment
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Motion palpation levels: C/S:____
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T/S:____
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L/S:____
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SI
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Sacrum
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Ankle Joint Dysfunction
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Hip Joint Dysfunction
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Knee Joint Dysfunction
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Shoulder Joint Dysfunction
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Elbow joint Dysfunction
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Wrist and Hand Joint Dysfunction
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R: Range of Motion Abnormality
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Visual cervical ROM with pain
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Visual lumbar ROM with pain
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T: Tone/ Tenderness
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Cervical Soft Tissue Findings
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Thoracic Soft Tissue Findings
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Lumbopelvic Soft Tissue Findings
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Upper Extremity Soft Tissue Findings
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Lower Extremity Soft Tissue Findings
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ASSESSMENT CC#1
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ASSESSMENT CC#2
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ASSESSMENT CC#3
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ASSESSMENT CC#4
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ASSESSMENT CC#5
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Additional Assessment
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Phase of Care
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Type of injury
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Suggested Treatment Plan
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Progress
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Treatment Procedure Plan
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Treatment goals for Chief Complaint #1
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Treatment goals for Chief Complaint #2
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Treatment goals for Chief Complaint #3
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Treatment goals for Chief Complaint #4
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Treatment goals for Chief Complaint #5
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Complicating Factors
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PLAN
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Treatment plan goals for the patients condition
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Chiropractic Technique
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C/S:____
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T/S:____
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L/S:____
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SacroIlliac Joint Manipulation
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ExtraSpinal Adjust
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Sacrum
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Extra spinal Manipulation
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Therapeutic Exercise:
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If Other, please mention
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Time____
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Exercise progression
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Active muscle therapy performed today
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Passive therapy performed today
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Passive therapy location
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Active therapy performed today
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Strapping location
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Supports and braces
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Additional Plan/Goals:______
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treatment plan goals statement
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Goals for care
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Additional treatment notes
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Change plan next visit
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Treatment plan Visit Number
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Of
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