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SUBJECTIVE
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History of Present Illness/Chief Complaint
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Current Complains
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Pain frequency
• • •
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Lower Back pain rating
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Remarks
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Lower Extremity Pain rating
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Remarks
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Past Medical History
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Stage of condition
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Cause of current episode
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Nature of condition
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VITAL SIGNS
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Weight
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Height
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Blood pressure
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OBJECTIVE
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Inspection
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Palpation
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SPINAL SYMPTOM RATING
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Disability Index
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Result
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ORTHOPEDIC TESTS
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Straight leg raise
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Note
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Hibb's Test
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Note
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Patrick's Test
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Note
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Valsalva maneuver
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Note
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Soto Hall Test- Result
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Note
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Kemp Test - Result
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Note
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Spinal Percussion - Result
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Note
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Range of Motion
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Trunk extension (AROM normal 30°) - current
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Trunk flexion (AROM normal 30°) - current
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Trunk left lateral flexion (AROM normal 35°) - current
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Trunk right lateral flexion (AROM normal 35°) - current
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Trunk left rotation (AROM normal 45°) - current
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Trunk right rotation (AROM normal 45°) - current
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Lumbarsacral extension (AROM normal 30°) - current
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Lumbarsacral flexion (AROM normal 80°) - current
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Lumbarsacral left lateral flexion (AROM normal 35°) - current
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Lumbarsacral right lateral flexion (AROM normal 35°) - current
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Lumbarsacral left rotation (AROM normal 45°) - current
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Lumbarsacral right rotation (AROM normal 45°) - current
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Hip flexion (AROM normal 120°) - current L
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Hip extension (AROM normal 30°) - current L
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Hip abduction (AROM normal 45°) - current L
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Hip extension (AROM normal 30°) - current R
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Hip flexion (AROM normal 120°) - current R
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Hip abduction (AROM normal 45°) - current R
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MUSCLE STRENGTH
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L Glut medius
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R Glut medius
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L Hamstrings
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R Hamstrings
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L Hip flexion
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R Hip flexion
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L Hip extension
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R Hip extension
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Back Extensors
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ASSESSMENT
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TODAY'S TREATMENT
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OFFICE NEW LOW 30 MIN: (99203)
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Rationale for manual therapy
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CHIROPRACT MANJ 3-4 REGIONS : (98941)
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Rationale for manual therapy
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CHIROPRACT MANJ 1-2 REGIONS : (98940)
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Rationale for manual therapy
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CHIROPRACT MANJ XTRSPINL 1/> : (98943)
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Rationale for manual therapy
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MECHANICAL TRACTION THERAPY : (97012)
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Rationale for manual therapy
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Therapeutic Exercise: (97110)
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Rationale for manual therapy
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Electric Stimulation : (G0283)
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Rationale for the procedure
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Electric Stimulation : (97014)
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Rationale for the procedure
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Manual Therapy: (97140)
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Rationale for manual therapy
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Short term goals
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Long term goals
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