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New Conditions:
Overall Condition: Better Worse Same Other
Describe How Better:
Describe How Worse:
What Aggravates:
What Improves:
On the drawing, place a number on the areas of injury and describe it using the letters
A = Achy Pain B = Burning Pain N = NumbnessS = Stabbing Pain P = Pins & Needles
M = Musc. Spasm
1. 1 5 10
2. 5. 1 5 10 1 5 10
3. 6. 1 5 10 1 5 10
4. 1 5 10
P lease f i l l out a l l the in fo rmat ion requested below - leave no b lanks
Initials_______
Pain
Spasm
ROM
C-Sp
T-Sp
L-Sp
Pelvis
U/L Ext
[ ] [ ] L [ ] R [ ] [ [
[ ] [ ] [ ] [ ]
[ ] [ ] [ ] [ ] L [ ] R
[ ] [ ] [ ] [ ] [
[ ] [ ] [ ] [ ]
[ ] [ ] L [ ] R [ ] [ ] [ ]
[ ] [ ] [ ] [ ]
[ ] [ ] [ ]
[ ] [ ] [ ] [ ]
[ ] [ ] [ ] [ ]
[ ] [ [ [
BedSd
IC XF EFF TP
P-A A-P Rib
FlMalPos ExMalPos FD Scol ] Kyph
IC XF EFF TP
SidePost Fd Scol Disc
IC XF EFF TP
SidePost Block Cat3
PI-L PI-R AS-L AS-R
IC XF EFF TP
IC ] XF ] EFF ] TP
Supine ] L ] R
S p a s m P a i n
C
T
L
P
C
T
L
P
SERVICES RENDERED
[ ] New Patient Exam[ ] Est. Patient Exam[ ] Re-Exam[ ] Report of Findings[ ] Consultation-Short[ ] Consultation-Long[ ] Emergency Service [ ] Adjustment[ ] Flexion Distraction[ ] Massage 1st Region[ ] Massage 2 Regions[ ] Massage 3 Regions[ ] Massage 1 Region Short[ ] Hot Packs[ ] UltraSound [ ] E-Stimulation[ ] US/E-Stim Combo[ ] Staff Office Visit[ ] Ltr 1 2 3 4[ ] Other ______
Please Sign When LeavingPatient Signature___________________________________________________
I hereby certify with my signature that:
- I have reviewed all dates of services and find them to be accurate.- All itemized services were performed and provided therapeutic benefit for my case.