|
SUBJECTIVE
|
|
|
History of Present Illness/Chief Complaint
|
|
|
Current Complains
|
|
|
Pain frequency
• • •
|
|
|
Neck Pain Rating
|
|
|
Remarks
|
|
|
Upper Extremity Pain Rating
|
|
|
Remarks
|
|
|
ADLs affected:
|
|
|
Past Medical History
|
|
|
Stage of condition
|
Cause of current episode
|
|
|
Other Causes:
|
|
Nature of condition
|
|
|
VITAL SIGNS
|
|
|
Weight
|
Height
|
|
Blood pressure
|
|
|
OBJECTIVE
|
|
|
Inspection
|
|
|
Postural Exam
|
|
|
Palpation
|
|
|
Restrictions:
|
|
|
SPINAL SYMPTOM RATING
|
|
|
Disability Index
|
Result
|
|
ORTHOPEDIC TESTS
|
|
|
Cervical Compression
|
Note
|
|
Cervical Distraction Test
|
Note
|
|
Bakody's sign
|
Note
|
|
Impingement Sign
|
Note
|
|
Speed's Test
|
Note
|
|
Valsalva maneuver
|
Note
|
|
Empty Can Test
|
Note
|
|
Spinal Percussion
|
Note
|
|
Neer's Test
|
Note
|
|
Hawkins / Kennedy Impingement Test
|
Note
|
|
Other Tests:
|
|
|
Range of Motion
|
|
|
Cervical Extension - Active
|
|
|
Cervical Flexion - Active
|
|
|
Left Cervical Rotation - Active
|
|
|
Right Cervical Rotation - Active
|
|
|
Right Lateral Flexion - Active
|
|
|
Left Lateral Flexion - Active
|
|
|
L Shoulder Flexion - Active
|
R Shoulder Flexion - Active
|
|
L Shoulder Extension - Active
|
R Shoulder Extension - Active
|
|
L Shoulder Abduction - Active
|
R Shoulder Abduction - Active
|
|
L Shoulder Internal Rotation - Active
|
R Shoulder Internal Rotation - Active
|
|
L Shoulder External Rotation - Active
|
R Shoulder External Rotation - Active
|
|
MUSCLE STRENGTH
|
|
|
Right Lateral Flexors
|
Left Lateral Flexors
|
|
Cervical Flexors
|
Cervical Extensors
|
|
Right Cervical Rotators
|
Left Lateral Flexors
|
|
Right Shoulder Flexion
|
Left Shoulder Flexion
|
|
Right Shoulder Extension
|
Left Shoulder Extension
|
|
Right Shoulder Abduction
|
Left Shoulder Abduction
|
|
Right Shoulder Internal Rotation
|
Left Shoulder Internal Rotation
|
|
Right Shoulder External Rotation
|
Left Shoulder External Rotation
|
|
Additional Areas:
|
|
|
ASSESSMENT
|
|
|
Diagnosis
|
|
|
TODAY'S TREATMENT
|
|
|
OFFICE NEW LOW 30 MIN: (99203)
|
Rationale
|
|
EST PATIENT EXPANDED (20 minutes): (99213)
|
Rationale
|
|
CHIROPRACT MANJ 3-4 REGIONS : (98941)
|
Rationale
|
|
CHIROPRACT MANJ 1-2 REGIONS : (98940)
|
Rationale
|
|
CHIROPRACT MANJ XTRSPINL 1/> : (98943)
|
Rationale
|
|
MECHANICAL TRACTION THERAPY : (97012)
|
Rationale
|
|
Therapeutic Exercise: (97110)
|
Rationale
|
|
Electric Stimulation : (G0283)
|
Rationale
|
|
Electric Stimulation : (97014)
|
Rationale
|
|
Manual Therapy: (97140)
|
Rationale
|
|
Electric Stimulation : (97032)
|
Rationale
|
|
98960 – Self-Management Education
|
Rationale
|
|
E0730 – TENS Unit (4-lead)
|
Rationale
|
|
Short term goals
|
|
|
|
|
|
Long term goals
|
|
