PROVIDER/CLINIC NAME______________________________________________________________________________
DATE OF VISIT ___/___/20___
Check All that Apply:
Patient____________________________________________ DOB________________
_____NEW PATIENT _____ RE-EVALUATION _____ NEW CONDITION _____ ROUTINE VISIT
FOR INITIAL EXAM OR NEW CONDITION, Please give first date you noticed symptoms ____________________________
FOR INITIAL EXAM OR NEW CONDITION, What is your major complaint? _______________________________________
SUBJECTIVE PAIN ASSESSMENT
Right
RATE YOUR PAIN
Left
Place an X on the drawings
to the left wherever you
have pain. Beside the X
indicate the type of pain you
are experiencing:
Back
Front
A=Ache
B=Burning
ST=Stabbing
SP=Spasm
N=Numbness
P=Pins and Needles
T=Throbbing
(Example: XST between
your shoulders mean you
have stabbing pain between
your shoulders)
PAIN SCALE: Please circle the number that best describes your overall pain:
0
NONE
2
LITTLE
5
MEDIUM
8
SEVERE
10
10+
EXCRUCIATING
PATIENT/LEGAL GUARDIAN SIGNATURE__________________________________________________________
Doctor/Provider Signature _____________________________________________________________________
PROVIDER/CLINIC NAME _____________________________________________________________________
DATE OF VISIT ___/___/20___
Patient____________________________________________ DOB_______
Check ONE: _____INITIAL EXAMINATION _____ RE-EVALUATION
C0
DATE
C1
_____ NEW CONDITION
USING ARROWS
ASYMMETRY
TISSUE ABNORMALITIES
Mark the Misaligned
Vertebrae
C2
C3
T1
C4
T2
C5
T3
A _______
B _______
C _______
T4
C6
C7
T5
D _______
T6
E _______
T7
F _______
T8
G _______
L1
L2
L3
T9
L4
H _______
T10
L5
T11
SAC
T12
I _______
Mark Tissue Abnormalities: TP=Trigger Points, LG=Ligaments
(Swollen/Tender), TN=Tendons, SK=Skin, FS=Fascial Restrictions,
SP=Spasm, TI=Tightness
L-IL
R-IL
RANGE OF MOTION ASSESSMENT
CERVICAL
NORMAL
Flexion
PAIN
LUMBAR
NORMAL
50
Flexion
60
Extension
60
Extension
25
Left Lat Flex
45
Left Lat Flex
25
Right Lat Flex
45
Right Lat Flex
25
Left Rotation
80
Left Rotation
30
Right Rotation
80
Right Rotation
30
PAIN
Doctor/Provider Signature _____________________________________________________________________
PROVIDER/CLINIC NAME _____________________________________________________________________
DATE OF VISIT ___/___/20___
Patient____________________________________________ DOB_______
Check ONE: _____INITIAL EXAMINATION _____ RE-EVALUATION
_____ NEW CONDITION
EXAMINATION
B/P: __________ PULSE: __________ RESP: __________ HT: __________WT: _________ GRIP: (L)______ (R)______
REFLEXES (Wexler Scale)
SENSORY: C5:______ C6:______ C7:______ C8:______ T1:______ L3:______
Biceps _____________
L4:______L5:______ S1:______
D=Deficit N=Normal
(L) or (R)
Triceps _____________
GENERAL ORTHO/NEURO EXAMINATION: (+) or (-), (L) or (R)
Brac/rad ____________
Spinous Percus: _________
Babinski __________ Brudzinski __________
Dejerine Triad __________
Rhomberg__________ Valsalva____________
(+)
INDICATION
Patella _____________
Achilles ____________
TEST
(-)
Distraction
Jackson
Max Cerv Root Compression
Cervical Compression
Soto Hall
Spurlings
Shoulder Depression
Libmans
Burns Bench
Hoovers
Bechterew
Beevors
Minors Sign
Ely
Fajersztajn
Nachlas
Gluteal Punch
Goldthwaite
Heel-toe Walk
Kemps
Lasague
Braggards
Supported Adams
Nerve Root Compression
Nerve Root Compression
Nerve Root Compression
Nerve Root Compression
(cerv) (thor) Vertebral Trauma
Nerve Root Irritation
Nerve Root Compression
(low) (normal) (high) Pain Threshold
(hysteria) (Malingering)
(hysterical paralysis) (Malingering)
Sciatic Disc Compression
Abdominal Muscle Weakness
Radicular Disc Pain
Upper Lumbar Lesion
Intervertebral Disc Syndrome
Upper Lumbar Lesion
Spinal Lesion
Lumbar Differentiation
5th Lumbar Motor Deficit
Intervetebral Disc Rupture
(Muscle) (Disc) (Nerve) Irritation
Lumbar Antalgic Spasm
Lumbosacral Differentiation
MUSCLE TESTS
LEVEL
C5
C6
C7
C8
Muscle
Deltoids
Biceps
Wrist Extensors
Triceps
Wrist Flexors
Finger Extensors
Finger Flexors
Muscle Grade
L:
R;
L:
R:
L:
R:
L:
R:
L:
R:
L:
R:
L:
R:
LEVEL
T1
L2-L3
L4-L5
L3-L4
L5-S1
L4-L5
S1-S2
Muscle
Finger Abductors
Hip Flexors
Hip Extensors
Knee Extensors
KneeFlexors
Ankle Extensors
Ankle Flexors
Muscle Grade
L:
R:
L:
R:
L:
R:
L:
R:
L:
R:
L:
R:
L:
R:
DIAGNOSIS: _________________________________________________________________________________
___________________________________________________________________________________________
DOCTOR SIGNATURE
______________________________________________________
DATE
______________________
