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Chief Complaint
• • •
|
CC status
|
|
% of day?
|
Other Symptoms
• • •
|
|
Severity of pain
|
Quality of pain
• • •
|
|
Radiate?
|
If yes, Where?
|
|
|
|
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Relieving Factors
• • •
|
Aggravating Factors
• • •
|
|
|
Symp. worst when?
|
|
|
|
|
Subluxation Complex
• • •
|
Spinal Palpation
• • •
|
|
L Spasm and Tenderness
• • •
|
R Spasm and Tenderness
• • •
|
|
Derifield Leg Check
|
Posture Analysis
• • •
|
|
Cervical Subluxation Complex
• • •
|
Thoracic Subluxation Complex
• • •
|
|
Lumbar Subluxation Complex
• • •
|
Records reviewed
• • •
|
|
|
|
|
Spinal Palp WNL
|
Pregnant/Websters
|
|
|
|
|
C1
• • •
|
C2
• • •
|
|
C3
• • •
|
C4
• • •
|
|
C5
• • •
|
C6
• • •
|
|
C7
• • •
|
Occiput
• • •
|
|
|
|
|
T1
• • •
|
T2
• • •
|
|
T3
• • •
|
T4
• • •
|
|
T5
• • •
|
T6
• • •
|
|
T7
• • •
|
T8
• • •
|
|
T9
• • •
|
T10
• • •
|
|
T11
• • •
|
T12
• • •
|
|
|
|
|
L1
• • •
|
L2
• • •
|
|
L3
• • •
|
L4
• • •
|
|
L5
• • •
|
|
|
|
|
|
Left Ilium
• • •
|
Right Ilium
• • •
|
|
Sacrum
• • •
|
Pubes
• • •
|
|
|
|
|
Plan- improving
• • •
|
Plan-at home
• • •
|
|
Function
• • •
|
Range of motion
• • •
|
|
PIRIFORMIS
|
Treatment Schedule
• • •
|
|
|
|
|
|
|
|
Psoas Stretch form
|
Wellness Adjustment
|
|
Core Stability Exercises
|
Posture Printout
|
|
Ice
|
|
