DIAGNOSIS & TREATMENT PLAN SCHEDULE

Name: _____________________________________ Case #: ________________ Date: _________________

Type of Injury: ‫ ٱ‬MVA ‫ ٱ‬RSI ‫ ٱ‬Lifting ‫ ٱ‬Sports ‫ ٱ‬WC ‫ ٱ‬Slip & Fall ‫ ٱ‬Trauma ‫ ٱ‬Unknown

COMPLETE PROBLEM LIST

DATE # COMPLAINT DIAGNOSIS TESTS ORDERED
1 New / Confirm
2 New / Confirm
3 New / Confirm
4 New / Confirm
5 New / Confirm

TREATMENT GOALS OUTCOME

Improve Pain Pallit. Arrested Avoid
DATE # Resolution
Function Relief Care Degen. Surgery
Prevention Date Resolve Referred

1
2
3
4
5

ADL QUESTIONNAIRE SCORES

DATE REV. OSWESTRY NECK DISABILITY OTHER SCORE

TREATMENT PLAN
DATE CMT
9894X
EMS
G0283
US
97035
MTX
97012
MFR
97140
MSG
97124
VPM
97016
REHAB
97110
NMR
97112
ADL
97535
Re-Exam
Date
TREATMENT FREQUENCY: _______ X / Week For _______ Weeks
DATE CMT
9894X
EMS
G0283
US
97035
MTX
97012
MFR
97140
MSG
97124
VPM
97016
REHAB
97110
NMR
97112
ADL
97535
Re-Exam
Date
TREATMENT FREQUENCY: _______ X / Week For _______ Weeks
DATE CMT
9894X
EMS
G0283
US
97035
MTX
97012
MFR
97140
MSG
97124
VPM
97016
REHAB
97110
NMR
97112
ADL
97535
Re-Exam
Date
TREATMENT FREQUENCY: _______ X / Week For _______ Weeks
DATE CMT
9894X
EMS
G0283
US
97035
MTX
97012
MFR
97140
MSG
97124
VPM
97016
REHAB
97110
NMR
97112
ADL
97535
Re-Exam
Date
TREATMENT FREQUENCY: _______ X / Week For ________Weeks

Physician Signature: _________________________, D.C.

Advanced Chiropractic, P.C. 807 E. McMurray Rd. Suite 103 Venetia, PA 15367 (724) 941-6800