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New Patient
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Subjective
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Chief Complaint
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Date of Injury
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Position in the vehicle
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Pedestrian
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Wearing Seat Belt
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Not wearing Seatbelt
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How impact occurred
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Type of Impact,where the vehicle
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Areas of Pain
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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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Pulses - normal
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Pulses Abnormal
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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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Lymph Exam - Normal
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Lymph exam Abnormal
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Posture
• • •
|
|
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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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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 Exam- Abnormal
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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
• • •
|
Cervical Spine Comments
|
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Lumbar Spine - Normal
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Lumbar Spine- Abnormal
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Lumbar Spine ROM
• • •
|
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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Neurological/Motor Exam Abnormal
|
|
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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
|
Neurological exam Comments
|
|
Reflexes
• • •
|
|
|
Sensory Exam normal
|
|
|
Sensory Exam As Indicated Below
|
|
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Sensory Exam RUE
• • •
|
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
|
Other pertinent exam findings
|
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Trigger Point Evaluation
|
|
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Splenius Capitis
|
Semispinalis Capitis
|
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Scalenes
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Upper Trapezius
|
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Lower Trapezius
|
Levator Scapulae
|
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Quadratus Lumbordum
|
Rhomboid
|
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Erector Spinae
|
Glute Medius
|
|
Piriformis
|
Other Muscle Spasms
|
|
Labs/Other Studies Reviewed
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