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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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Neck/Upperback pain rating
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Remarks
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Shoulder 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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Spurling's Test
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Note
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Cervical Distraction Test
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Note
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Bakody's sign
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Note
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Impingement Sign
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Note
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Speed's Test
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Note
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Empty Can Test
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Note
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Spinal Percussion - Result
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Range of Motion
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Cervical Extension - Active
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Cervical Flexion - Active
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Left Cervical Rotation - Active
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Right Cervical Rotation - Active
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Right Lateral Flexors
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Left Cervical Rotation - Active
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Shoulder Flexion - Active
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Note
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Shoulder Extension - Active
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Note
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Shoulder Abduction - Active
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MUSCLE STRENGTH
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Cervical Flexors
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Cervical Extensors
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Right Cervical Rotators
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Left Cervical Rotators
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Right Lateral Flexors
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Left Lateral Flexors
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Right Shoulder Flexion
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Left Shoulder Flexion
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Right Shoulder Extension
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Left Shoulder Flexion
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Right Shoulder Abduction
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Left Shoulder Abduction
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Right Shoulder Internal Rotation
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Left Shoulder Internal Rotation
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Right Shoulder External Rotation
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Left Shoulder External Rotation
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ASSESSMENT
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Diagnosis
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Plan of Care
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OFFICE NEW LOW 30 MIN: (99203)
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Rationale
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EST PATIENT EXPANDED (30 minutes): (99213)
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Rationale
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CHIROPRACT MANJ 3-4 REGIONS : (98941)
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Rationale
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CHIROPRACT MANJ 1-2 REGIONS : (98940)
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Rationale
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CHIROPRACT MANJ XTRSPINL 1/> : (98943)
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Rationale
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MECHANICAL TRACTION THERAPY : (97012)
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Rationale
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Therapeutic Exercise: (97110)
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Rationale
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Electric Stimulation : (G0283)
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Rationale
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Electric Stimulation : (97014)
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Rationale
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Manual Therapy: (97140)
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Rationale
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Short term goals
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Long term goals
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