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New Patient
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Subjective
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Chief Complaint
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HPI
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REVIEW OF SYSTEMS
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ROS: As Indicated on Intake Sheet
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ROS: As Indicated Below
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ROS: Constitutional
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ROS: HEENT
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ROS: Endocrinologic
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ROS: Gastrointestinal
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ROS: Genitourinary
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ROS: Integumentary
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ROS: Cardiovascular
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ROS: Respiratory
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ROS: Musculoskeletal
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ROS: Hematologic/Immunologic
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ROS: Psychiatric
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ROS: Neurologic
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Objective
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PHYSICAL EXAM
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General WNL
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General Abnormal
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General Comments
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HEENT WNL
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HEENT Abnormal
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HEENT Comments
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Skin WNL
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Skin Lesion
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Skin Comments
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Cardiovascular WNL
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Cardiovascular Abnormal
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Cardiovascular Comments
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Lungs WNL
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Lungs Abnormal
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Lungs Comments
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Abdomen WNL
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Abdomen Abnormal
• • •
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Abdomen Comments
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Pulses - normal
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Pulses Abnormal
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Lymph Exam - Normal
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Lymph exam Abnormal
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MSK WNL
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MSK Abnormal
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Other joint exam
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MSK Comments
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Posture
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Gait normal
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Gait Abnormal
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Gait comments
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Cervical Exam - Normal
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Cervical Spine ROM
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Cervical Pain
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Cervical Ortho Tests (+)
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Cervical Ortho Tests (-)
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Palpation
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Cervical Spine Comments
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Lumbar Spine - Normal
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Lumbar Spine ROM
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Lumbar ROM Pain
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Lumbar Ortho Tests (+)
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Lumbar Ortho Tests (-)
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Palpation
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Lumbar Comments
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Neurological Exam - Motor Normal
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Motor Exam comments
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Shoulder Abductors (C5)
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Brachioradialis (C6)
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Wrist Extensors (C7)
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APB (Median nerve/C8)
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FDI/ADM
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Hip Flexion (L1-L2)
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Knee extension (L3)
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Ankle Dorsiflexion (L4)
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EHL/1st Toe Extension
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Gastrocnemius/heel raises (S1)
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Neurological Exam - As Listed Below
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Neurological exam Comments
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Reflexes normal
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Reflexes Abnormal
• • •
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Sensory Exam normal
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Sensory Exam As Indicated Below
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Sensory Exam RUE
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Sensory Exam LUE
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Sensory Exam RLE
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Sensory Exam LLE
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Peripheral Nerve Signs
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Sensory Exam comments
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Other pertinent exam findings
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Trigger Point Evaluation
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Splenius Capitis
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Semispinalis Capitis
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Scalenes
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Upper Trapezius
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Lower Trapezius
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Levator Scapulae
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Quadratus Lumbordum
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Rhomboid
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Erector Spinae
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Glute Medius
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Piriformis
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Other Muscle Spasms
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Labs/Other Studies Reviewed
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ASSESSMENT
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Diagnosis
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Assessment
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ASSESSMENT (Comments)
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PLAN:
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PLAN: Radiology
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PLAN: Physical Therapy
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PLAN: Labs
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PLAN: Referrals
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PLAN: General Instructions
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PLAN : Education
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Total time spent
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FOLLOW-UP
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Plan Comments
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