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HEADER
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Initial/Reevaluation/New Region Evaluation
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SOAP Subjective Intro
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Referring Doctor's address
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Attn: Dr./Mr./Ms. (add title)
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Attn Dr. Intro
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Patient's assessed improvement
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History/Subjective:
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Car Accident
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Car Accident
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Date of Accident
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Relative speed at impact
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Patient's vehicle was?
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Driver/Passenger
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Struck on the
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Aware of accident prior to impact?
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Air bags deployed?
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Vehicle type?
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Other driver's vehicle
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Time of day?
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Road conditions
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What did patient strike in car
• • •
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What did the patient strike in the car (other)?
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Loss of Consciousness?
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Brakes applied during accident?
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Did the seat break?
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Driver's hands
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Head apparel
• • •
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Body position at time of impact
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Looking
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Seatbelts?
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Where did patient go?
• • •
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Symptoms
• • •
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When were the symptoms felt
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Additional Evaluations
• • •
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Additional Treatment
• • •
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Imaging and treatment?
• • •
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Getting better/worse
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Difficulty:
• • •
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Prior Motor Vehicle Accidents
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Car accident free form
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HISTORY - WORK INJURY
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Work Injury
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Date of Injury
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Description of Injury
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Injury was reported to employer?
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Where did patient go?
• • •
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Immed. Pain
• • •
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Additional Providers
• • •
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Imaging and treatment?
• • •
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Additional Treatment
• • •
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Additional Treatment Free Form
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Getting better/worse
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Difficulty:
• • •
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Prior Work Injuries
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Occupation
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Work Status
• • •
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History / Subjective
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Initial Comments
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Current Symptoms
• • •
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Area of pain
• • •
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Location
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Onset
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Date of Onset (specific date)
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Date of Onset (blank text box)
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Mechanism of Injury
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Palliative
• • •
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Provocative
• • •
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radiation
• • •
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Denies Radiation
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VAS
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Intensity
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Frequency
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Timing
• • •
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Nature of Pain
• • •
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Other Doctors
• • •
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No other care before today.
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History of Illness
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Night sweats / Unexplained Weight Loss
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In what position do you sleep?
• • •
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Do you sleep with a pillow?
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How Many?
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Sleep
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Amount of sleep interruption
• • •
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Medical Records Presented
• • •
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Other comments
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H&P Med / Fam / Social History
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Medical History
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Past Medical History Unremarkable
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Past Medical History
• • •
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Past Medical History Comments
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Hospitalization History:
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Past Surgical History Unremarkable Yes/No
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Past Surgical History:
• • •
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Past Surgical History Comments
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Immunization Status:
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Immunization Comments:
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Gyne History:
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Gynecologic history
• • •
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Comments: (Other)
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Family History
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Unremarkable
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Family MH
• • •
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Comments
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Father's MH
• • •
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Mother's MH
• • •
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Comments
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Sibling(s)' MH
• • •
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Comments
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Children(s)' MH
• • •
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Comments
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Social History
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Marital Status
• • •
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Marital Status Comments:
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Living Arrangements
• • •
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Living Arrangement Comments:
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Occupation:
• • •
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Occupation; free text
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Alcohol Use
• • •
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Alcohol use comments:
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Tobacco
• • •
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Tobacco use comments:
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Caffeine
• • •
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Caffeine use comments:
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Exercise
• • •
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Exercise comments:
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Patient's diet
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H&P Review of Systems
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General
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General
• • •
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General Comments
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Skin
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Skin
• • •
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Skin Comments
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HEENT
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HEENT
• • •
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HEENT Comments
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Neck
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Neck
• • •
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Neck Comments
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Breasts
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Breasts
• • •
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Breasts Comments
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Cardiovascular
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Cardiovascular
• • •
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Cardiovascular Comments
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Respiratory
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Respiratory
• • •
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Respiratory Comments
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Gastrointestinal
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GI
• • •
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GI Comments
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Urinary
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Urinary
• • •
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Urinary Comments
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Genital Male
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Genital (male)
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Genital (Male)
• • •
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Genital (Male) Comments
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Genital Female
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Genital (female)
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Genital (Female)
• • •
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Genital (Female) Comments
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Peripheral Vascular
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Periph. Vasc.
• • •
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Periph. Vasc. Comments
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Musculoskeletal
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MSK
• • •
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MSK Comments
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Neurological
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Neurological
• • •
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Neurological Comments
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Endocrine
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Endocrine
• • •
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Endocrine Comments
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Psychiatric
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Psychiatric
• • •
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Psychiatric Comments
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H&P Physical Exam
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General
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General WNL
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General Abnormal
• • •
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General Comments
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HEENT
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HEENT WNL
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HEENT Abnormal
• • •
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HEENT Comments
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Skin
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Skin WNL
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Skin Lesion? Click here
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Skin Comments
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Skin lesion comments
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Neck
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Neck WNL
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Neck Abnormal
• • •
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Neck Comments
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Cardiovascular
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Cardiovascular WNL
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Cardiovascular Abnormal
• • •
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Cardiovascular Comments
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Lungs
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Lungs WNL
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Lungs Abnormal
• • •
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Lungs Comments
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Abdomen
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Abdomen WNL
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Abdomen Abnormal
• • •
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Abdomen Comments
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Musculoskeletal
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MSK WNL
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MSK Abnormal
• • •
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MSK Comments
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Breasts
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Breasts WNL
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Breasts Abnormal
• • •
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Breasts Comments
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Neurological
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Neuro WNL
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Neuro Abnormal
• • •
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Neuro Comments
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Extremities
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Extremities WNL
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Extrem Abnormal
• • •
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Extremities Comments
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Objective
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Observation:
• • •
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Gait WNL
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Gait
• • •
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Examination Other
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C/S
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Visual:
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Palpation:
• • •
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Palpation side
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Palpation Intensity
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Tender Facets
• • •
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Palpation (Trigger Points)
• • •
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Spinal/Extremity listings
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Palpatory Evaluation
• • •
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Joint Disfunction
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Cervical ROM:
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All C/S ROM WNL?
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Flexion
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With Pain?
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Within normal limits
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Extension
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With Pain?
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Within normal limits
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Rt. Rot
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With Pain?
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Within normal limits
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Lt. Rot
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With Pain?
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Within normal limits
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Right Lat. Flex
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With Pain?
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Within normal limits
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Left Lat. Flex
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With Pain?
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Within normal limits
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Cervical Spine Orthopedic Tests
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Cervical Compression Test
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Soto Hall Test
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Right Max. C/S compression
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Klein's Maneuver
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Left Max. C/S Comp. Test
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Valsalva's Maneuver
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Cervical Distraction
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Heel Walk
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Jacksons Cervical test
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Toe Walk
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Right Shoulder Depression Test
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Left Shoulder Depression Test
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Spinous Percussion Test
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Bakodys
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Adsons
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U.E. myotomes
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All upper extremity myotomes WNL?
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Left C4 Trapezius
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Rt.
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Left C5 Deltoid
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Rt.
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Left C6 Biceps Brachii
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Rt.
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Left C7 Triceps Brachii
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Rt.
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Left C8 finger flexion
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Rt.
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Left T1 finger abduction
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Rt.
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Upper Extremity Myotome Testing w/Pain
• • •
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Light touch
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All upper extremity dermatomes WNL?
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All lower extremity dermatomes WNL?
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Left C5
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Right C5
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Left C6
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Right C6
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Left C7
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RIght C7
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Left C8
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Right C8
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Left T1
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Right T1
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Left L4
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Right L4
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Left L5
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Right L5
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Left S1
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Right S1
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Comment
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Thoracic:
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Visual:
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Palpation
• • •
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Palpation side
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Palpation Intensity
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Tender Facets
• • •
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Palpation (Trigger Points)
• • •
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Thoracic ROM:
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All T/S ROM WNL?
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Flexion
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With Pain?
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Within normal limits
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Extension
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With Pain?
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Within normal limits
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Rt. Rot
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With Pain?
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Within normal limits
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Lt. Rot
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With Pain?
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Within normal limits
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Right Lat. Flex
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With Pain?
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Within normal limits
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Left Lat. Flex
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With Pain?
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Within normal limits
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Thoracic Spine Orthopedic Tests
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Adams Sign
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Soto Hall Test
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Spinous Percussion
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Chest Expansion Test
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Right Shoulder Depression Test
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Left Shoulder Depression Test
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Valsalva's Maneuver
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Rib listings
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T1
• • •
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T2
• • •
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T3
• • •
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T4
• • •
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T5
• • •
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T6
• • •
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T7
• • •
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T8
• • •
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T9
• • •
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T10
• • •
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T11
• • •
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T12
• • •
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L/S:
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Visual:
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Palpation
• • •
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Palpation Side
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Palpation Intensity
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Tender Facets
• • •
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Palpation (Trigger Points)
• • •
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Lumbar AROM:
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All lumbar spine ROM WNL?
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Flexion
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With Pain?
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Within normal limits
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Extension
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with pain?
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Within normal limits
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Rt. Rot
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With pain?
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Within normal limits
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Lt. Rot
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with pain?
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Within normal limits
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Rt. Lat. Flex
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With pain?
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Within normal limits
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Lt.Lat. Flex
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With pain?
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Within normal limits
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Pelvis
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Pelvis
• • •
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Lumbar Spine Orthopedic Tests
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Trendelenburg
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Spinous Percussion Test
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Dejerines Triad
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Interspinous Palpation
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Minors sign
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Intermamillary Palpation
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SLR
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Bechterew's Test
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Braggards
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Klein's Maneuver
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Well Leg Raise
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Valsalva's Maneuver
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Milgram's
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Slump Test
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Yeoman's Test
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Hibb's Test
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Toe Walk
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Heel Walk
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Kemp's
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Sitting Root Sign
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L.E. Myotomes
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Lower extremity myotomes WNL
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Left Iliopsoas (L2)
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Right Iliopsoas (L2)
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Left Quadriceps Femoris (L3)
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Right Quadriceps Femoris (L3)
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Left Biceps Femoris (L4)
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Right Biceps Femoris (L4)
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Left Great Toe Extension (L5)
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Right Great Toe Extension (L5)
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Left Ankle Plantarflexion (S1)
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Right Ankle Plantarflexion (S1)
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Lower Extremity Myotome Testing w/Pain
• • •
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DTRs
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All upper extremity DTR's WNL?
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All lower extremity DTR WNL?
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Lt C5
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Rt
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Lt. C6
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Rt
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Lt. C7
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Rt
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L4 Lt.
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Rt
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L5 Lt.
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Rt
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S1 Lt.
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Rt
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EXTREMITY EVALUATIONS
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Shoulder Exam
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Shoulder Exam
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(L) Shoulder
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(R) Shoulder
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Pain Diagram
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Observation
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Observation WNL
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Bruising
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[+] Bruising Comments
• • •
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Swelling
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[+] Swelling Comments
• • •
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Redness
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[+] Redness Comments
• • •
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ABN Posture
• • •
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Atrophy
• • •
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AC Joint Step Defect
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GH Sulcus Sign
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Observation Comments
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Shoulder ROM Exam
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ROM WNL
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Shoulder Objective Other
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Flexion (180)
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Flexion Symptoms
• • •
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Extension (50)
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Extension Symptoms
• • •
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Abduction (180)
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ABD Symptoms
• • •
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Adduction (35)
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ADD Symptoms
• • •
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Internal Rotation (90)
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IR Symptoms
• • •
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External Rotation (80)
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ER Symptoms
• • •
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Horizontal ABD (30)
|
Horiz. ABD Symptoms
• • •
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Horizontal Adduction (130)
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Horiz. ADD Symptoms
• • •
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[+} Painful Arc
• • •
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Motor Function
|
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Grade 5/5
• • •
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Grade 4/5
• • •
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Grade 3/5
• • •
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Grade 2/5
• • •
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Grade 1/5
• • •
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Grade 0/5
• • •
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Pain with MMT
• • •
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Othopedic Tests
|
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Codman's Test
|
[+] Codman's Test
• • •
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Dugas Test
|
[+] Dugas Test
• • •
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Apley's Test
|
[+] Apley's Test
• • •
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|
Lift-Off Test
|
|
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Hawkins-Kennedy Test
|
[+] Hawkins-Kennedy Test
• • •
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Neer's Test
|
[+] Neer's Test
• • •
|
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Empty Can Test
|
[+] Empty Can Test
• • •
|
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Speed's Test
|
|
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Yergason's Test
|
[+] Yergason's Test
• • •
|
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Clunk Test
|
[+] Clunk Test
• • •
|
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O'Brien's Test
|
[+] O'Brien's Test
• • •
|
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Kim Test
|
|
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Anterior Apprehension Test
|
[+] Anterior Apprehension Test
• • •
|
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Posterior Apprehension Test
|
[+] Posterior Apprehension Test
• • •
|
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Load & Shift Test
|
[+] Load & Shift Test
• • •
|
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Dawburns Test
• • •
|
Palpation
• • •
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Palpation
|
Palpation (multiple mm)
• • •
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|
Elbow Exam
|
|
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ELBOW EXAM
|
|
|
(L) Elbow
|
(R) Elbow
|
|
Pain Diagram (Snap photo on iPhone or iPad or Upload image to markup)
|
|
|
Observation
|
Observation WNL
|
|
Bruising
|
[+] Bruising Comments
• • •
|
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Swelling
|
[+] Swelling Comments
• • •
|
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Redness
|
[+] Redness Comments
• • •
|
|
ABN Posture
• • •
|
Atrophy
• • •
|
|
Observation Comments
|
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Elbow ROM Exam
|
ROM WNL
|
|
Flexion (150)
|
Flexion Symptoms
• • •
|
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Extension (0)
|
Extension Symptoms
• • •
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Supination (90)
|
Supination Symptoms
• • •
|
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Pronation (90)
|
Pronation Symptoms
• • •
|
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Motor Function
|
|
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Grade 5/5
• • •
|
Grade 4/5
• • •
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Grade 3/5
• • •
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Grade 2/5
• • •
|
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Grade 1/5
• • •
|
Grade 0/5
• • •
|
|
Pain with MMT
• • •
|
|
|
Othopedic Tests
|
|
|
Varus Stress Test
|
[+] Varus Stress Test
• • •
|
|
Cozen's Test
|
[+] Cozen's Test
• • •
|
|
Reverse Cozen's Test
|
[+] Reverse Cozen's Test
• • •
|
|
Mill's Test
|
[+] Mill's Test
• • •
|
|
Reverse Mill's Test
|
[+] Reverse Mill's Test
• • •
|
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Upper Extremity Exam
|
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Upper Extremity Exam
|
|
|
Shoulder Exam (upper extremity exam)
|
|
|
SHOULDER AROM
|
|
|
(L) Shoulder Flexion (180)
|
Flexion Symptoms
• • •
|
|
(L) Shoulder Extension (50)
|
Extension Symptoms
• • •
|
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(L) Shoulder Abduction (180)
|
ABD Symptoms
• • •
|
|
(L) Shoulder Adduction (35)
|
ADD Symptoms
• • •
|
|
(L) Shoulder Int Rot (90)
|
IR Symptoms
• • •
|
|
(L) Shoulder Ext Rot (80)
|
ER Symptoms
• • •
|
|
(L) Shoulder Horiz ABD (30)
|
Horiz. ABD Symptoms
• • •
|
|
(L) Shoulder Horiz ADD (130)
|
Horiz. ADD Symptoms
• • •
|
|
L Shoulder AROM all WNL
|
|
|
|
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(R) Shoulder Flexion (180)
|
Flexion Symptoms
• • •
|
|
(R) Shoulder Extension (50)
|
Extension Symptoms
• • •
|
|
(R) Shoulder Abduction (180)
|
ABD Symptoms
• • •
|
|
(R) Shoulder Adduction (35)
|
ADD Symptoms
• • •
|
|
(R) Shoulder Int Rot (90)
|
IR Symptoms
• • •
|
|
(R) Shoulder Ext Rot (80)
|
ER Symptoms
• • •
|
|
(R) Shoulder Horiz ABD (30)
|
Horiz. ABD Symptoms
• • •
|
|
(R) Shoulder Horiz ADD (130)
|
Horiz. ADD Symptoms
• • •
|
|
R Shoulder AROM all WNL
|
|
|
SHOULDER ORTHO
|
|
|
(L) Painful Arc [+}
• • •
|
(R) Painful Arc [+}
• • •
|
|
Subacromial Push Button (L)
|
Subacromial Push Button (R)
|
|
Impingement Sign (L)
|
Impingement Sign (R)
|
|
Codman's Drop Arm Test (L)
|
Codman's Drop Arm Test (R)
|
|
Adson's Test (L) (Ant. Scal. TOS)
|
Adson's Test (R) (Ant. Scal. TOS)
|
|
Apley's Scratch Test (L)
|
Apley's Scratch Test (R)
|
|
Yergason's Test
• • •
|
|
|
Empty Can
• • •
|
|
|
Hawkin's - Kennedy
• • •
|
|
|
Neer's test
• • •
|
|
|
Speeds Test
• • •
|
|
|
Elbow Exam (upper extremity exam)
|
|
|
ELBOW AROM
|
|
|
(L) Elbow Flexion (150)
|
Flexion Symptoms
• • •
|
|
(L) Elbow Extension (0)
|
Extension Symptoms
• • •
|
|
(L) Elbow Pronation (90)
|
Pronation Symptoms
• • •
|
|
(L) Elbow Supination (90)
|
Supination Symptoms
• • •
|
|
L Elbow AROM all WNL
|
|
|
|
|
|
(R) Elbow Flexion (150)
|
Flexion Symptoms
• • •
|
|
(R) Elbow Extension (0)
|
Extension Symptoms
• • •
|
|
(R) Elbow Pronation (90)
|
Pronation Symptoms
• • •
|
|
(R) Elbow Supination (90)
|
Supination Symptoms
• • •
|
|
R Elbow AROM all WNL
|
|
|
ELBOW ORTHO
|
|
|
Elbow Varus Stress Test
|
Extension Stress Test
|
|
Elbow Valgus Stress Test
|
Mill's Test
|
|
Cozen's Test (L) Tennis Elbow
|
Cozen's Test (R) Tennis Elbow
|
|
Reverse Cozen's Test (L)
|
Reverse Cozen's Test (R)
|
|
Wrist Exam (upper extremities exam)
|
|
|
WRIST AROM
|
|
|
(L) Wrist Flexion (80)
|
Flexion Symptoms
• • •
|
|
(L) Wrist Extension (70)
|
Extension Symptoms
• • •
|
|
(L) Radial Deviation (20)
|
Rad. Dev. Symptoms
• • •
|
|
(L) Ulnar Deviation (30)
|
Ulnar Dev. Symptoms
• • •
|
|
L Wrist AROM all WNL
|
|
|
|
|
|
(R) Wrist Flexion (80)
|
Flexion Symptoms
• • •
|
|
(R) Wrist Extension (70)
|
Extension Symptoms
• • •
|
|
(R) Radial Deviation (20)
|
Rad. Dev. Symptoms
• • •
|
|
(R) Ulnar Deviation (30)
|
Ulnar Dev. Symptoms
• • •
|
|
R Wrist AROM all WNL
|
|
|
WRIST ORTHO
|
|
|
Allen's Test (L)
|
Allen's Test (R)
|
|
Left Tinel's Test (+)
|
Right Tinel's Test (+)
|
|
Flexion Stress Test (L)
|
Flexion Stress Test (R)
|
|
Extension Stress Test (L)
|
Extension Stress Test (R)
|
|
Dellon's 2 Pt. Discrimination Test (L)
|
Dellon's 2 Pt. Discrimination Test (R)
|
|
Phalen's Test
|
|
|
Comments / Freeform
|
|
|
Hip Exam
|
|
|
Hip Exam
|
|
|
(L) Hip
|
(R) Hip
|
|
Pain Diagram (take photo on iPad or iPhone or upload image
|
|
|
Observation
|
Hip Observation WNL
|
|
Bruising
|
[+] Bruising Comments
• • •
|
|
Swelling
|
[+] Swelling Comments
• • •
|
|
Redness
|
[+] Redness Comments
• • •
|
|
ABN Posture
• • •
|
Observation Comments
|
|
Hip ROM Exam
|
HIP ROM WNL
|
|
Flexion w/ Knee F (120)
|
Flexion w/ Knee F Symptoms
• • •
|
|
Flexion SLR (90)
|
Flexion SLR Symptoms
• • •
|
|
Extension (30)
|
Extension Symptoms
• • •
|
|
Abduction (50)
|
ABD Symptoms
• • •
|
|
Adduction (30)
|
ADD Symptoms
• • •
|
|
Internal Rotation (40)
|
IR Symptoms
• • •
|
|
External Rotation (50)
|
ER Symptoms
• • •
|
|
Motor Function
|
|
|
Grade 5/5
• • •
|
Grade 4/5
• • •
|
|
Grade 3/5
• • •
|
Grade 2/5
• • •
|
|
Grade 1/5
• • •
|
Grade 0/5
• • •
|
|
Pain with MMT
• • •
|
|
|
Othopedic Tests
|
|
|
Allis' Sign
|
[+] Allis' Sign
• • •
|
|
Anvil Test
|
[+] Anvil Test
• • •
|
|
FABERE Test
|
[+] FABERE Test
• • •
|
|
Laguerre's Test
|
[+] Laguerre's Test
• • •
|
|
SLR Active
|
[+] SLR Active
• • •
|
|
SLR Passive
|
[+] SLR Passive
• • •
|
|
Ober's Test
|
[+] Ober's Test
• • •
|
|
Modified Thomas Test
|
[+] Modified Thomas Test
• • •
|
|
Hibb's Test
|
[+] Hibb's Test
• • •
|
|
Yeoman's Test
|
[+] Yeoman's Test
• • •
|
|
Knee Exam
|
|
|
Knee Exam
|
|
|
(L) Knee
|
(R) Knee
|
|
Pain Diagram
|
|
|
Observation
|
Observation WNL
|
|
Bruising
|
[+] Bruising Comments
• • •
|
|
Swelling
|
[+] Swelling Comments
• • •
|
|
Redness
|
[+] Redness Comments
• • •
|
|
Atrophy
• • •
|
Aberrant Lateral Patellar Tracking
|
|
Aberrant Medial Patellar Tracking
|
ABN Knee Posture
• • •
|
|
Observation Comments
|
|
|
Knee ROM Exam
|
ROM WNL
|
|
Flexion (150)
|
Flexion Symptoms
• • •
|
|
Extension (0)
|
Extension Symptoms
• • •
|
|
Internal Rotation (5)
|
IR Symptoms
• • •
|
|
External Rotation (5)
|
ER Symptoms
• • •
|
|
Motor Function
|
MMT WNL
|
|
Grade 5/5
• • •
|
Grade 4/5
• • •
|
|
Grade 3/5
• • •
|
Grade 2/5
• • •
|
|
Grade 1/5
• • •
|
Grade 0/5
• • •
|
|
Pain with MMT
• • •
|
|
|
Othopedic Tests
|
|
|
Patellar Apprehension
|
[+] Patellar Apprehension Test
• • •
|
|
Fouchet's Test
|
[+] Fouchet's Test
• • •
|
|
Clarke's Test
|
|
|
Bounce Home Test
|
[+] Bounce Home Test
• • •
|
|
Valgus Stress @ 0
|
[+] Valgus Stress @ 0
• • •
|
|
Valgus Stress @ 30
|
[+] Valgus Stress @ 30
• • •
|
|
Varus Stress @ 0
|
[+] Varus Stress @ 0
• • •
|
|
Varus Stress @ 30
|
[+] Varus Stress @ 30
• • •
|
|
Anterior Drawer
|
[+] Anterior Drawer
• • •
|
|
Posterior Drawer
|
[+] Posterior Drawer
• • •
|
|
Lachman's Test
|
[+] Lachman's Test
• • •
|
|
McMurray's Test
|
[+] McMurray's Test
• • •
|
|
Pivot Shift Test
|
[+] Pivot Shift Test
• • •
|
|
Hughston's Plica Test
|
|
|
Apley's Compression Test
|
|
|
Apley's Distraction Test
|
[+] Apley's Distraction Test
• • •
|
|
Hyperflexion Compression Test
|
[+] Hyperflexion Compression Test
• • •
|
|
Othopedic Tests Comments
|
|
|
Foot & Ankle Exam
|
|
|
Foot & Ankle Exam
|
|
|
(L) Foot/ Ankle
|
(R) Foot/ Ankle
|
|
Pain Diagram (use iphone or iPad) No photo uploaded
|
|
|
Observation
|
Observation WNL
|
|
Bruising
|
[+] Bruising Comments
• • •
|
|
Swelling
|
[+] Swelling Comments
• • •
|
|
Redness
|
[+] Redness Comments
• • •
|
|
ABN Foot Posture
• • •
|
Observation Comments
|
|
Ankle ROM Exam
|
Ankle ROM WNL
|
|
ROM WNL
|
|
|
Plantar Flexion (40)
|
Plantar Flexion Symptoms
• • •
|
|
Dorsiflexion (20)
|
Dorsiflexion Symptoms
• • •
|
|
Inversion (20)
|
Inversion Symptoms
• • •
|
|
Eversion (10)
|
Eversion Symptoms
• • •
|
|
Motor Function
|
MMT WNL
|
|
Grade 5/5
• • •
|
Grade 4/5
• • •
|
|
Grade 3/5
• • •
|
Grade 2/5
• • •
|
|
Grade 1/5
• • •
|
Grade 0/5
• • •
|
|
Pain with MMT
• • •
|
|
|
Othopedic Tests
|
|
|
Anterior Drawer Neutral
|
[+] Anterior Drawer Neutral
• • •
|
|
Anterior Drawer Plantarflexed
|
[+] Anterior Drawer p/f
• • •
|
|
Posterior Drawer Neutral
|
[+] Posterior Drawer Neutral
• • •
|
|
Posterior Drawer Plantarflexed
|
[+] Posterior Drawer p/f
• • •
|
|
Inversion Talar Tilt Neutral
|
[+] Inversion Talar Tilt Neutral
• • •
|
|
Inversion Talar Tilt Plantarflexed
|
[+] Inversion Talar Tilt p/f
• • •
|
|
Eversion Talar Tilt
|
[+] Eversion Talar Tilt
• • •
|
|
Rotational Stress Test
|
[+] Rotational Stress Test
• • •
|
|
Achilles Squeeze Test
|
Hoffa's Test
|
|
Thompson's Test
|
[+] Thompson's Test
• • •
|
|
Calaneal Squeeze Test
|
[+] Calcaneal Squeeze Test
• • •
|
|
Homan's Sign
|
[+] Homan's Sign
• • •
|
|
Morton's Squeeze Test
|
Tinel's Test at the Ankle
|
|
Ankle Impingement Prediction Rules
• • •
|
|
|
Lower Extremity Exam
|
|
|
Lower Extremity Exam
|
|
|
Hip Exam
|
|
|
HIP AROM
|
|
|
(L) Hip Flexion (130)
|
Flexion Symptoms
• • •
|
|
(L) Hip Extension (30)
|
Extension Symptoms
• • •
|
|
(L) Hip ABduction (50)
|
ABD Symptoms
• • •
|
|
(L) Hip ADduction (30)
|
ADD Symptoms
• • •
|
|
(L) Hip Int Rot (40)
|
IR Symptoms
• • •
|
|
(L) Hip Ext Rot (50)
|
ER Symptoms
• • •
|
|
(L) Hip AROM all WNL
|
|
|
|
|
|
(R) Hip Flexion (130)
|
Flexion Symptoms
• • •
|
|
(R) Hip Extension (30)
|
Extension Symptoms
• • •
|
|
(R) Hip ABduction (50)
|
ABD Symptoms
• • •
|
|
(R) Hip ADduction (30)
|
ADD Symptoms
• • •
|
|
(R) Hip Int Rot (40)
|
IR Symptoms
• • •
|
|
(R) Hip Ext Rot (50)
|
ER Symptoms
• • •
|
|
(R) Hip AROM all WNL
|
|
|
HIP ORTHO
|
|
|
Patrick's Test (L)
|
Patrick's Test (R)
|
|
Hibb's Test (L)
|
Hibb's Test (R)
|
|
Knee Exam
|
|
|
KNEE AROM
|
|
|
(L) Knee Flexion (150)
|
Flexion Symptoms
• • •
|
|
(L) Knee Extension (-5)
|
Extension Symptoms
• • •
|
|
(L) Knee Int Rot (5)
|
Int Rot Symptoms
• • •
|
|
(L) Knee Ext Rot (5)
|
Ext Rot Symptoms
• • •
|
|
(L) Knee AROM all WNL
|
|
|
|
|
|
(R) Knee Flexion (150)
|
Flexion Symptoms
• • •
|
|
(R) Knee Extension (-5)
|
Extension Symptoms
• • •
|
|
(R) Knee Int Rot (5)
|
Int Rot Symptoms
• • •
|
|
(R) Knee Ext Rot (5)
|
Ext Rot Symptoms
• • •
|
|
(R) Knee AROM all WNL
|
|
|
KNEE ORTHO
|
|
|
PA Drawer Test (L) ACL
|
PA Drawer Test (R) ACL
|
|
AP Drawer Test (L) PCL
|
AP Drawer Test (R) PCL
|
|
Wilson's Test (L)
|
Wilson's Test (R)
|
|
Clark's Sign (L)
|
Clark's Sign (R)
|
|
Genu Valgum Test (Knocked Knee)
|
Genu Varum Test (Bow Legged)
|
|
McMurray's Test (L)
|
McMurray's Test (R)
|
|
Patella Apprehension Test (L)
|
Patella Apprehension Test (R)
|
|
Ankle / Foot Exam
|
|
|
ANKLE / FOOT AROM
|
|
|
(L) Plantar Flexion (40)
|
Plantar Flexion Symptoms
• • •
|
|
(L) Dorsi Flexion (20)
|
Dorsi Flexion Symptoms
• • •
|
|
(L) Subtalar Inversion (20)
|
Inversion Symptoms
• • •
|
|
(L) Subtalar Eversion (10)
|
Eversion Symptoms
• • •
|
|
L Ankle AROM all WNL
|
|
|
|
|
|
(R) Plantar Flexion (40)
|
Plantar Flexion Symptoms
• • •
|
|
(R) Dorsi Flexion (20)
|
Dorsi Flexion Symptoms
• • •
|
|
(R) Subtalar Inversion (20)
|
Inversion Symptoms
• • •
|
|
(R) Subtalar Eversion (10)
|
Eversion Symptoms
• • •
|
|
R Ankle AROM all WNL
|
|
|
ANKLE / FOOT ORTHO
|
|
|
Foot Drawer Test (L)
|
Foot Drawer Test (R)
|
|
Lateral Stability Test (L)
|
Lateral Stability Test (R)
|
|
Medial Stability Test (L)
|
Medial Stability Test (R)
|
|
Tinel's Foot Test (L)
|
Tinel's Foot Test (R)
|
|
Bancroft's Test (L) - (Thrombophlebitis)
|
Bancroft's Test (R) - (Thrombophlebitis)
|
|
Lowenberg's Test (L) - (Thrombosis)
|
Lowenberg's Test (R) - (Thrombosis)
|
|
Allis Test (L Short)
|
Allis Test (R Short)
|
|
Comments / Freeform
|
|
|
Detailed Cranial Nerve Exam
|
|
|
Start Neurological Exam
|
|
|
Deep Tendon Reflexes
• • •
|
Comments
|
|
Babinski
|
Clonus
|
|
Cranial Nerve I
• • •
|
Deviated Septum/ Previous Injury
|
|
CN 2/3 RIGHT
|
CN2/3 Right Eye
• • •
|
|
CN 2/3 LEFT
|
CN 2/3 LEFT
• • •
|
|
V:A Ratio RIGHT
|
V:A Ratio LEFT
|
|
Oculomotor Exam CN 3, 4, 6 WNL
|
|
|
Hypertropia
|
Lateral Skew
|
|
Gaze Stability intact
|
Gaze Stability
• • •
|
|
LEFT PURSUITS
• • •
|
Quality of Left Pursuits
|
|
Right PURSUITS
• • •
|
Quality of Right Pursuits
|
|
Leftward Saccades WNL
|
Quality of Leftward Saccades
• • •
|
|
Rightward Saccades WNL
|
Quality of Rightward Saccades
• • •
|
|
Cranial Nerve 5 WNL
|
CN 5 Senory/Motor
• • •
|
|
Cranial Nerve 7 WNL
|
CN 7 Grading
• • •
|
|
Cranial Nerve 8 WNL
|
CN 8 Grading
• • •
|
|
Cranial Nerve 9 WNL
|
CN 9 Grading
• • •
|
|
Cranial Nerve 10 WNL
|
CN 10 Grading
• • •
|
|
Cranial Nerve 11
|
CN 11 Grading
• • •
|
|
Cranial Nerve 12 WNL
|
CN 12 Tongue Deviation
• • •
|
|
SFMA
|
|
|
Active Cervical Flexion
|
ACF Breakout
• • •
|
|
Active Cervical Extension
|
ACE Breakout
• • •
|
|
Cervical Rotation - Lateral Bend
|
AC Rotation Breakout
• • •
|
|
Upper Extremity Pattern 1
|
Upper Extremity Breakout
• • •
|
|
Upper Extremity Pattern 2
|
Upper Extremity Breakout
• • •
|
|
Multi Segmental Flexion
|
Multi Segmental Flexion Breakout
• • •
|
|
Multi Segmental Extension
|
Multi Segmental Extension Breakout
• • •
|
|
Multi Segmental Rotation
|
Multi Segmental Rotation Breakout
• • •
|
|
Single Leg Stance
|
Single Leg Stance Breakout
• • •
|
|
Overhead Deep Squat
|
Overhead Deep Squat
• • •
|
|
Additional comments
|
|
|
Functional Assessment Screen
|
|
|
Single Leg Stand Left
|
Single Leg Stand Right
|
|
Standing Squat
• • •
|
|
|
Standing Left Knee Lift
• • •
|
Standing Right Knee Lift
• • •
|
|
Left Hip Internal Rotation
|
Right Hip Internal Rotation
|
|
Left Hip External Rotation
|
Right Hip External Rotation
|
|
Wall Angel
• • •
|
Wall Push Up
• • •
|
|
Supine Head Lift
|
Founder
• • •
|
|
ASSESSMENT
|
|
|
Assessment
|
|
|
Diagnosis
• • •
|
Comments on DX
|
|
Complicating Factors
• • •
|
Assessed Improvement
|
|
Prognosis
|
Additional Goals
|
|
Comments
|
|
|
Plan:
|
|
|
Plan
|
|
|
Treatment Schedule
• • •
|
Treatment Plan Details
• • •
|
|
Home Care Recommendations
• • •
|
Short/Long Term Goals
• • •
|
|
Achieved Goals
• • •
|
Reexams
|
|
Services Performed
• • •
|
Chiro Manip
|
|
Joint CMT
• • •
|
Extremity CMT
|
|
Areas adjusted
• • •
|
Areas Adjusted Other
|
|
ART
• • •
|
ART Duration
|
|
PIR
• • •
|
PIR Duration
|
|
Static Stretching
• • •
|
Stretching Duration
|
|
STM
• • •
|
STM Duration
|
|
STM Type
• • •
|
|
|
IASTM
• • •
|
IASTM Duration
|
|
Hot Pack
• • •
|
Hot Pack Duration
|
|
Ice Pack
• • •
|
Ice Pack Duration
|
|
EMS
• • •
|
EMS Duration
|
|
EMS Type
• • •
|
|
|
US
• • •
|
US Setting
|
|
Mechanical Traction
• • •
|
Mechanical Traction Duration
|
|
LLLT
• • •
|
KT
• • •
|
|
Exercise (1 set of 10 reps)
• • •
|
Exercise (2 sets of 10 reps)
• • •
|
|
Exercise (3 sets of 10 reps)
• • •
|
Exercise stretches
• • •
|
|
Exercise Free Form
|
Exercise Duration
|
|
Nurtitional/ Botanical Supplements
• • •
|
Home Care
• • •
|
|
Other Treatment
|
|
|
Post Treatment Response
|
Post Tx Notes
|
|
E/M time
|
|
|
X-Ray Orders
• • •
|
Blood Work Orders
• • •
|
|
MRI Orders
• • •
|
MSK Ultrasound
• • •
|
|
Referral
• • •
|
Referral
|
|
Comments
|
|
