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C/C #1
• • •
|
VAS C/C
|
|
C/C#1 Frequency
|
VAS C/C with Activity
|
|
|
|
|
C/C #2
• • •
|
VAS C/C
|
|
C/C#2 Frequency
|
VAS C/C with Activity
|
|
|
|
|
C/C #3
• • •
|
VAS C/C
|
|
C/C#3 Frequency
|
VAS C/C with Activity
|
|
|
|
|
C/C #4
• • •
|
VAS C/C
|
|
C/C#4 Frequency
|
VAS C/C with Activity
|
|
|
|
|
C/C #5
• • •
|
VAS C/C
|
|
C/C#5 Frequency
|
VAS C/C with Activity
|
|
|
|
|
C/C #6
• • •
|
VAS C/C
|
|
C/C#6 Frequency
|
VAS C/C with Activity
|
|
|
|
|
SBW Last Visit
|
Overall Improvement
|
|
Click if no change
|
|
|
Compliant with Exercises
|
HIITS
|
|
Last visit feel good?
|
|
|
Additional Subjective
|
ADLs
• • •
|
|
Asymmetry
|
Subluxation
• • •
|
|
ROM
|
|
|
Spinal Area
|
Pain ROM
• • •
|
|
Spinal Area
|
Pain ROM
• • •
|
|
Spinal Area
|
Pain ROM
• • •
|
|
Non Spinal Active ROMs
• • •
|
|
|
Tissue Change
|
Muscle Spasms
• • •
|
|
Additional Objective
|
|
|
Exam
|
|
|
Phase Of Care
|
Response To Care
|
|
New Dx
|
|
|
Progress Noted?
|
|
|
Condition # 1 Assessment
|
Condition # 1 Complicating Factors
• • •
|
|
Condition # 2 Assessment
|
Condition #2 Complicating Factors
• • •
|
|
Condition #3 Assessment
|
Condition #3 Complicating Factors
• • •
|
|
Causation (put on 2nd visit)
|
|
|
Additional Assessment
|
|
|
Adjustment
• • •
|
Drift and George's Performed
|
|
Heat
|
|
|
Traction
|
Estim
|
|
Exercises
• • •
|
TE time (minutes)
|
|
Bike/Arm Bike/Treadmill
• • •
|
Theraband Red
|
|
Trigger Point Release
|
Theraband Yellow
|
|
Ultrasound
• • •
|
US time (minutes)
|
|
MFR
|
|
|
NMR
• • •
|
NMR Mod
• • •
|
|
NMR Time (Min)
|
|
|
Acupuncture
|
AC for Neck Pain
|
|
|
Acu for LBP
|
|
|
AC Pain (General)
|
|
|
AC for Shoulder Pain?
|
|
|
AC for Elbow Pn
|
|
|
AC for Knee Pain
|
|
Response to Treatment
|
Adverse Reaction Yes
|
|
Responded Well To Treatment
|
Time off Work
|
|
Purpose of Next Visit
|
MD Referral
|
|
Additional Plan
|
|
|
Verbal IC given
|
MMI Achieved?
|
