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SUBJECTIVE
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◎ Cheif Complaint
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◎ Onset
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Mechanism of Injury
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◎ Progress and Response to Treatment
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◎ Pain
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◎ A. Description
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◎ B. Pain scale
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◎ B. Pain scale
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C. Frequency of Pain
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D. Factors that increase pain
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E. Factors that decrease pain
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Patient's Goal
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Past Medical History
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Past Medical History - Comment
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Past Surgery History
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Surgeon & Date
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SUBJECTIVE - ADDTIONAL COMMENT
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OBJECTIVE
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OBSERVATION
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◎ CERVICAL RANGE OF MOTION (ROM)
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[RE] ROM - % Improvement
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◎ A. Flexion
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ROM - additional comment
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◎ B. Extension
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ROM - additional comment
• • •
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C. Right Rotation
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ROM - additional comment
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D. Left Rotation
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ROM - additional comment
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E. Right lateral flexion
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ROM - additional comment
• • •
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F. Left lateral flexion
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ROM - additional comment
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MUSCLE STRENGTH
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A. Flexion
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B. Extension
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C. Right Side Bending
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D. Left Side Bending
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E. Right Rotation
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F. Left Rotation
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SENSATION
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Palpation (tenderness, swelling, etc)
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Palpation muscle gruop
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NECK DISABILITY INDEX
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SPECIAL TEST
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Gait Analysis
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Ambulation
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OBJECTIVE - ADDTIONAL COMMENTS
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ASSESSMENT
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Functional Limitation
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◎ Problem List
• • •
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◎ Short Term Goal
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◎ A. STG (Pain)
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◎ B. STG (ROM)
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◎ C. STG (Strength)
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D. STG (Balance & Mobility)
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[RE]
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◎ Long Term Goal
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◎ LTG - 1
• • •
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◎ LTG - 2
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◎ LTG - 3
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[RE] Continued skilled PT
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Progress
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Motivation (Acute / Choronic)
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ASSESSMENT - ADDITIONAL COMMENTS
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PLAN
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1 Unit TherEx
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2 Units TherEx
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1 Manual Therapy
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2 Manual Therapy
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1 Unit NeuroMuscular Education
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2 Unit NeuroMuscular Education
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1 Unit - Therapeutic activities (97530)
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2 Unit - Therapeutic activities (97530)
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3 Unit - Therapeutic activities (97530)
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4 Unit - Therapeutic activities (97530)
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Follow-Up
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[RE] Follow-Up
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PLAN - ADDITIONAL COMMENTS
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Insurance
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REFERRING PHYSICIAN (List)
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REFERRING PHYSICIAN - DIAGNOSIS
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Covering Provider
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111
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