Date: ____/____/_______

___________________________________________________

Patient's Name

SUBJECTIVE COMPLAINTS
The patient entered the office reporting that, in general, their overall conditi
on has:
Improved-----No Change----- Worsened
since their last office visit. Complaints today include the following:
Pain
Level
HEADACHE:
Occipital Frontal Temporal Global
L / R
Minimal Mild
Moderate
Severe
____
NECK:

Pain
Stiffness
Paresthesia
Minimal Mild
Moderate
Severe

Spasm

L / R
____

UPPER BACK:

Pain
Stiffness
Paresthesia
Spasm
L / R
Minimal Mild
Moderate
Severe
____
MIDBACK:
Pain
Stiffness
Paresthesia
Spasm
L / R
Minimal Mild
Moderate
Severe
____
LOWBACK:
Pain
Stiffness
Paresthesia
Spasm
L / R
Minimal Mild
Moderate
Severe
____
UPPER EXTR:
Pain
Stiffness
Paresthesia
Spasm
L / R
Minimal Mild
Moderate
Severe
____
LOWER EXTR: Pain
Stiffness
Paresthesia
Spasm
L / R
Minimal Mild
Moderate
Severe
____
Shoulder__Elbow__Wrist__Fingers____Hip____Knee____Ankle___Toes____ Notes:___
_____________________________
________________________________________________________________________________
________________________
OBJECTIVE / EXAMINATION
Muscle / Myofascial Hypertonicity was present in the following paraspinal region
s with the following degree of intensity.
(Key: 1 = Minimal, 2 = Mild, 3 = Mild to Moderate, 4 = Moderate, 5 = Mod
erate to Severe, 6 = Severe)
CERVICAL
__L / __ R Suboccipital
__L / __ R Mid Cervic
al
__L / __ R Upper Trapezius
THORACIC
__L / __ R Paraspinal
__L / __ R Mid Scapu
lar
__L / __ R Lower Trapezius
LUMBOSACRAL
__L / __ R Upper Paraspinal
__L /
__ R Lower Paraspinal
__L / __ R Piriformis / Psoas
Range of Motion, was evaluated with the following findings:
___Global
___Segmental
___Both
( Level of Restriction Key: 1 = Minimal, 2 = Mild, 3 = Mild to Moderate
, 4 = Moderate, 5 = Moderate to Severe, 6 = Severe)
Cervical : ___L / ___R
Thoracic: ___L / ___R Lumbar: ___L / ___R
Extremity.____________: ___L / ___R
ASSESSMENT / ACTION
____________
___L / ___R
___ Patient is improved ___ Patient is unchanged
___ Patient is worsened
____Exacerbation
______New injury
Joint misalignments / Fixations were detected in the following areas:---- Misalignment/fixations adjusted without incident
C0, C1, C2, C3, C4, C5, C6, C7 ___________________________ (prone
: supine: diversified
T1, T2, T3, T4, T5, T6, T7, T8, T9, T10, T11, T12 ____________
_________ (diversified)
L1, L2, L3, L4, L5, Sac, L-Ilium, R-Ilium _______ (diversified)
L / R Shoulder, L / R Elbow, L / R Wrist, L / R Hip, L / R Kn

ee, L / R Ankle, __________ (instr: manual: drop)

PLAN /PROTOCOL/ RECOMMENDATIONS
Based upon presenting symptoms, objective findings and clinical assessme
nt, treatment consisted of the following procedures:
___ Chiropractic Manipulative Therapy ___CMT 1-2, ___ CMT 3-4, ___ Extremity
__________________________
Therapeutics Modalities: Myofascial Release -- Mechanical Traction -- EMS/I
F -- Hot/Cold Therapy -- InfraRed
Ultrasound(attended) Pulsed/Con.__________ Massage Therapy-15/30min.____
_
Location____________________________________Inten
sity_________Time___________
Kinetic / Therapeutic Activity__
Neuromuscular Re-Ed___
Attend
ed Active Exercise______________________________
Location_____________________________________Time
: 15min. / 30min. Stretching
Strengthening / Conditioning
Dr.'s Initi
als______________ Frequency of Treatments_____________
___ Home Instruction: ___ Ice Therapy, ______ Traction _______,
Strapping/Ta
ping_______________________________
___ Personal Stretch / Exercise Program: __ neck, __ back, __ UE, __ LE, __ whol
e body, ____________________________
The following recommendations are made for Clinical Management of this p
atient: MMI Dismissal (Failure to Follow Treatment Plan)
___ Continue Care Plan, ____ Modify Care Plan, ___ Re-Examination, ___ Refer
ral for Further Evaluation: _____________
___ Referral for diagnostic / imaging assessment to include: ______________
COMMENTS:_______________________________________________________________________
________________________________
________________________________________________________________________________
___________________________________
________________________________________________________________________________
___________________________________
Goals___________________________________________________________________________
___________________________________
________________________________________________________________________________
___________________________________
Doctor's Signature_______________________________D.C.
ignature____________________________________________

Patient's S