|
History/Subjective:
|
|
|
Chief complaint, latest symptoms
|
Performing home care Rx?
|
|
Area of pain
• • •
|
Location
|
|
Onset
|
Date of Onset
|
|
Mechanism of Injury
|
Palliative
• • •
|
|
Provocative
• • •
|
tingling/numbness
• • •
|
|
Denies Numbness/Tingling
|
VAS
|
|
Nature of Pain
• • •
|
Other Doctors
• • •
|
|
No other care before today.
|
History of Illness
|
|
Frequency
|
Timing
• • •
|
|
Interrupts Sleep
|
Night Sweats
|
|
Other comments
|
|
|
Objective
|
|
|
Observation:
• • •
|
Gait
• • •
|
|
AK Scan
|
|
|
AK Scan All Strong
|
Muscle Testing Scan
• • •
|
|
Priority Muscle Test
• • •
|
|
|
No Stressors Identified
|
Specific Stressors:
|
|
Cervical Spine
|
|
|
Palpation:
• • •
|
Tender Facets
• • •
|
|
Comments:
|
|
|
Thoracic:
|
|
|
Spinous Percussion
|
Palpation
• • •
|
|
Tender Facets
• • •
|
Comments:
|
|
Lumbar
|
|
|
Palpation (Spasm)
• • •
|
Tender Facets
• • •
|
|
Comments:
|
|
|
Cervical ROM:
|
|
|
Flexion
|
With pain?
|
|
Extension
|
With pain?
|
|
Rt. Rot
|
With pain?
|
|
Lt. Rot
|
With pain?
|
|
Lt.Lat. Flex
|
With pain?
|
|
Rt.Lat. Flex
|
With pain?
|
|
Comments:
|
|
|
Thoracolumbar AROM:
|
|
|
Flexion
|
With pain?
|
|
Extension
|
With pain?
|
|
Lt. Rot
|
With pain?
|
|
Rt. Rot
|
With pain?
|
|
Lt.Lat. Flex
|
With pain?
|
|
Rt.Lat. Flex
|
With pain?
|
|
Comments:
|
|
|
SOT Listing
|
|
|
SOT Listing
• • •
|
|
|
Spinal listings
|
|
|
Occiput
|
C1
|
|
C2
|
C3
|
|
C4
|
C5
|
|
C6
|
C7
|
|
T1
|
T2
|
|
T3
|
T4
|
|
T5
|
T6
|
|
T7
|
T8
|
|
T9
|
T10
|
|
T11
|
T12
|
|
L1
|
L2
|
|
L3
|
L4
|
|
L5
|
Sacrum
|
|
Coccyx
|
|
|
Cervical Spine Orthopedic Tests
|
|
|
Cervical Compression Test
|
Right Max. Compression Test
|
|
Left Max. Compresion Test
|
Cervical Distraction
|
|
Shoulder Depression
|
Valsalva
|
|
ULTT Median
|
Soto-Hall
|
|
Comments:
|
|
|
Lumbar Spine Orthopedic Tests
|
|
|
SLR
|
Braggards
|
|
Psoas Muscle
|
Shepellman's test
|
|
Milgram's
|
Kemp's
|
|
Yeomans
|
Nachlas
|
|
Hibbs
|
Hip Scour
|
|
Thomas-Gaenslen's test
|
Slump Test
|
|
Minors sign
|
Log Roll
|
|
Anvil
|
Patrick/FABERE
|
|
Comments:
|
|
|
|
|
|
Extraspinal listings
|
|
|
LT TMJ
|
RT TMJ
|
|
LT S.I.
|
RT S.I.
|
|
LT Rib 1
|
RT Rib 1
|
|
LT Rib 2
|
RT Rib 2
|
|
LT Rib 3
|
RT Rib 3
|
|
LT Rib 4
|
RT Rib 4
|
|
LT Rib 5
|
RT Rib 5
|
|
LT Rib 6
|
RT Rib 6
|
|
LT Rib 7
|
RT Rib 7
|
|
LT Rib 8
|
RT Rib 8
|
|
LT Rib 9
|
RT Rib 9
|
|
LT Rib 10
|
RT Rib 10
|
|
LT Rib 11
|
RT Rib 11
|
|
LT Rib 12
|
RT Rib 12
|
|
LT SC joint
|
RT SC joint
|
|
LT AC joint
|
RT AC joint
|
|
LT GH joint
|
RT GH joint
|
|
LT radius
|
RT radius
|
|
LT ulna
|
RT ulna
|
|
LT carpals
|
RT carpals
|
|
LT hand
|
RT hand
|
|
LT hip joint
|
RT hip joint
|
|
LT tibia
|
RT tibia
|
|
LT fibula
|
LT fibula
|
|
LT ankle
|
RT ankle
|
|
LT foot
|
RT foot
|
|
Shoulder Exam
|
|
|
Palpation
• • •
|
Which side
|
|
Comments:
|
|
|
Shoulder AROM:
|
|
|
Left Shoulder Flexion
|
Right Shoulder Flexion
|
|
Left Shoulder Extension
|
Right Shoulder Extension
|
|
Left Shoulder Abduction
|
Right Shoulder Abduction
|
|
Left Shoulder Adduction
|
Right Shoulder Adduction
|
|
Left Shoulder ER
|
Right Shoulder ER
|
|
Left Shoulder IR
|
Right Shoulder IR
|
|
Comments:
|
|
|
Shoulder orthopedic exams
|
|
|
Apley's Scratch 1 (Ext Rot)
• • •
|
Apley's Scratch 2 (Int Rot)
• • •
|
|
Dugas
• • •
|
Speeds Test
• • •
|
|
Yergason's Test
• • •
|
Trumpeter
• • •
|
|
Empty Can
• • •
|
Hug/Napoleon
• • •
|
|
Liftoff
• • •
|
O'Brien
• • •
|
|
Crank
• • •
|
Clunk
• • •
|
|
Hawkin's - Kennedy
• • •
|
Neer's test
• • •
|
|
AC shear/pinch
• • •
|
Comments:
|
|
Elbow/Wrist/Hand
|
|
|
Observation:
• • •
|
|
|
Palpation (Spasm)
• • •
|
Palpation comment:
|
|
Elbow/Wrist/Hand AROM
|
|
|
Right Elbow Extension
|
Right Elbow Flexion
|
|
Left Elbow Extension
|
Left Elbow Flexion
|
|
Right Forearm Pronation
|
Right Forearm Supination
|
|
Left Forearm Pronation
|
Left Forearm Supination
|
|
Right Wrist Extension
|
Right Wrist Flexion
|
|
Left Wrist Extension
|
Left Wrist Flexion
|
|
Left Finger Flexion
|
Right Finger Flexion
|
|
Left Thumb Adduction
|
Right Thumb Adduction
|
|
Comments:
|
|
|
Elbow/Wrist/Hand Orthopedics
|
|
|
Cozen's
• • •
|
Reverse Cozen's
• • •
|
|
Mill's
• • •
|
Reverse Mill's
• • •
|
|
Tinel's elbow test
• • •
|
Phalen's
• • •
|
|
Reverse Phalen's
• • •
|
Finkelstein's
• • •
|
|
Froment's Cone
• • •
|
Thumb-pinky pinch
• • •
|
|
Comments:
|
|
|
Knee/Ankle/Foot
|
|
|
Observation:
• • •
|
|
|
Palpation (Spasm)
• • •
|
Comments on palpation:
|
|
Knee/Ankle/Foot AROM
|
|
|
Right Knee Extension
|
Right Knee Flexion
|
|
Left Knee Extension
|
Left Knee Flexion
|
|
Right Ankle Dorsiflexion
|
Right Ankle Plantarflexion
|
|
Left Ankle Dorsiflexion
|
Left Ankle PlantarFlexion
|
|
Comments:
|
|
|
Knee/Ankle/Foot Orthopedics
|
|
|
Thessaly
• • •
|
Single Leg Stand
• • •
|
|
Anterior Drawer Test
• • •
|
Posterior Drawer Test
• • •
|
|
Apley Compression Test
• • •
|
Apley Distraction Test
• • •
|
|
Lachman
• • •
|
McMurray's test
• • •
|
|
Patellar Grind
• • •
|
Patellar Facet Pinch
• • •
|
|
Valgus
• • •
|
Varus
• • •
|
|
Anterior Drawer ANKLE Test
• • •
|
Ankle Compression Test
• • •
|
|
Eversion Stress Test
• • •
|
Inversion Stress Test
• • •
|
|
Kleiger's
• • •
|
Thompson's Squeeze
• • •
|
|
Metatarsal Squeeze
• • •
|
Bunion Stress
• • •
|
|
Comments:
|
|
|
Assessment
|
|
|
NP/Re-Exam Assessment
|
|
|
Diagnosis
• • •
|
Comments on DX
|
|
Prognosis
• • •
|
Benefit from Care today: Yes / No
|
|
PARQ Conference?
• • •
|
PARQ for MINORS
• • •
|
|
Comments
|
|
|
Daily SOAP Assessment
|
|
|
Assessment:
• • •
|
Comments:
|
|
Plan:
|
|
|
Treatment Frequency month:
• • •
|
Treatment Duration Month
|
|
Treatment Frequency Weeks:
• • •
|
Treatment Duration week
|
|
Re-examination:
|
OPS after Tx today:
|
|
Non-Force Manipulation Used
|
Spinal Manipulation
• • •
|
|
Extraspinal Manipulation
• • •
|
Manual Therapy Techniques 97140
• • •
|
|
Therapeutic Exerciser 97110-59
• • •
|
IASTM 97140
• • •
|
|
Hot/Cold Pack 97010
• • •
|
Vibracussion (G5) 97140
• • •
|
|
Myofascial cupping 97140
• • •
|
Mechanical Traction 97012
• • •
|
|
Supplies
• • •
|
Radiology
• • •
|
|
Laboratory
• • •
|
Records reviewed
• • •
|
|
Handout Given
• • •
|
Questionnaire Given
• • •
|
|
Follow up:
|
Comments
|
