|
Texas Wellness Center
|
|
|
Chart ID:
|
Date:
|
|
Patient Name:
|
Date of Incident:
|
|
Date of Birth:
|
Gender:
|
|
Medical Report
|
|
|
Chief Complaint/ History of Present Illness:
|
|
|
Incident Details:
|
|
|
Past Medical/Surgical History:
|
|
|
Allergies:
|
|
|
Current Medications:
|
|
|
Initial Medical Evaluation:
|
|
|
Physical Examination:
|
|
|
1) HEENT:
|
|
|
2) Respiratory System:
|
|
|
3) Gastrointestinal System
|
|
|
4) Renal System
|
|
|
5) Reproductive System
|
|
|
6) Musculoskeletal System
|
|
|
6.1 - Spine
|
|
|
Cervical Region:
|
Lumbar Region:
|
|
Thoracic Region:
|
Sacroiliac Region:
|
|
6.2 - Upper Extremity
|
|
|
Shoulder:
|
|
|
Arm:
|
|
|
Elbow:
|
|
|
Forearm:
|
|
|
Wrist:
|
|
|
Hand:
|
|
|
6.3 - Chest
|
|
|
Sternum:
|
|
|
Rib Cage:
|
|
|
Scapula:
|
|
|
6.4 - Abdomen
|
|
|
List Findings:
|
|
|
6.5 - Lower Extremity
|
|
|
Pelvis:
|
Ankle
|
|
Knee:
|
Foot:
|
|
Diagnostic Test
|
Diagnosis
|
|
Plan
|
|
|
1) Physical Therapy:
|
|
|
Signature:
|
Date:
|
