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 ______

( ) Improving ( ) Sltly Wrs ( ) Mch Wrs ( ) Flare Sx

( ) Imprved ( ) Slt Imprv ( ) No Chng ( ) Sltly Wrs ( ) Mch Wrs

( ) Stable ( ) Improving

( ) Refer ( ) New Sx

( ) Slt Imprv ( ) Same

( ) Deteriorating ( ) No Imprvmnt

( ) Cont Estab Tx Plan ( ) Change Plan

Since Last Visit:

After Today’s TX:

Case Impression:

Name _________________________ Date ____________________

Thoracic Segmental DysfunctionThoracic Sprain/Strain

Thoracic Disc DegenerationDisc Herniation - w/ Myelopathy (.71)Spondylosis - w/ Myelopathy (.42)

Rib Sprain/Strain

Vertebral Motor Unit Instability

Aberrant Motion

Intercostal NeuralgiaParesthesia

MyospasmAtrophy

Thoracic Subluxation

Thoracic Spine Osteoarthritis

Chest Pain

Facet Joint Fixation

Ligament LaxityScoliosisKyphosisSpinal Anomalies OsteoporosisThoracic Outlet Syndrome

Myofascitis - Trigger Points

739.3

847.2

722.1O721.3

724.6718.48718.8#

719.9#

839.69

782.O

728.85728.2

722.52724.8

839.2O724.02

846.9839.42

Complicated By:

737.3O

738.6738.5738.6737.42

756.1O756.17738.4756.15724.4724.3

729.1

Lumbar Segmental Dysfunction

Lumbar Sprain/Strain

Disc Herniation - w/Myelopathy (.73)Spondylosis - w/Myelopathy (.42)

LumboSacroiliac Disorder/InsabilityFacet Joint FixationVertebral Motor Unit Instability

Aberrant Motion

Tortipelvis

Lumbosacral RadiculitisSciatic RadiculitisParesthesia

MyospasmAtrophy

Lumbar Disc DegenerationLumbar Facet Syndrome

Lumbar SubluxationLumbar Stenosis

Sacroiliac Sprain/StrainSacroiliac Subluxation

Scoliosis (idiopathic)

Pelvic Obliquety / UnlevelingUnilateral Limb Length DeficiencyIncr/Decr Sacral Base AngleIncr/Decr Lumbar Angle/Curve (.41)

Congenital Anomalies (unspec)Spina Bifida OccultaSpondylolysthesisSacralization

Myofascitis - Trigger Points

Cervical Segmental DysfunctionCervical Sprain/Strain

Cervical Disc DegenerationDisc Herniation // w/ Myelopathy (.71)Spondylosis // w/ Myelopathy ( .1)

Vertebral Motor Unit Instability

Suboccipital Neuralgia

Paresthesia

MyospasmTorticollis

Cervical Subluxation

Cervico Brachial SyndromeThoracic Outlet SyndromeTension Headache - PsychogenicHeadache Referable to NeckCommon MigraineTMJ Disorders

Cervical Kyphosis - Reversed Curve

Facet Joint FixationAberrant MotionLigament LaxityCervical Nerve Root Injury

Radicular Neuralgia

Stenosis Cervical SpineSpinal AnnomaliesOsteoporosisMyofascitis - Trigger Points

Atrophy

739.2847.1

722.51722.11721.2

848.3

718.48719.9#

353.O

782.O

728.85728.2

839.21

721.2

786.5

Complicated By:722.11

728.4737.3O737.1O756.1O733.O

353.8

729.1

739.1847.O

722.4

722.O723.3

718.8#

719.9#

729.2782.O

728.85723.5

839.O8

721.O

353.O307.81723.9346.1524.6

Complicated By:738.2

718.48

728.4953.O784.O

724.O756.1O733.O729.1

728.2

Cervcial Thoracic

Lumbar

Carpal Tunnel SyndromeTennis Elbow/Lateral EpicondylitisRotator Cuff Capsulitis/Syndr (.19)Finger Sprain/StrainWrist Sprain/StrainShoulder Sprain/StrainInjury to:Elbow BursitisShoulder BursitisDerangement: (area)Myospasm

Patelofemoral SyndromePsoas Insufficiency SyndromeCalcaneal SpurPes Plannus / Flat FootGait AbnormalityDifficulty WalkingKnee InflamationKnee OsteoarthritisAnkle Foot Sprain/StrainKnee Sprain/StrainHip Sprain/StrainAchilles TendonitisPatellar TendonitisCalcaneal BursitisKnee BursitisInjury to:Derangement: (area) Myospasm

836.5726.5726.73734.O781.2719.79716.66715.06845.O844.9843.9726.71726.64726.79726.6959.#718.8#728.85

Upper Extremity

Lower Extremity

Use for 718.#, 719.#

0 - Site Unspecified 1 - Shoulder 2 - Upper Arm 3 - Forearm 4 - Hand 5 - Pelvis and Thigh

6 - Lower Leg 7 - Ankle and Foot 8 - Other Specified Sites 9 - Multiple Sites

Use for 959.#

0 - Head, Face & Neck 1 - Trunk 2 - Shoulder & Upper Arm 3 - Forearm 4 - Hand 5 - Finger

6 -Pelvis and Thigh 7 - Lower Leg, Ankle and Foot 8 - Other Specified & Multiple Sites 9 - Site Unspecified

354.O726.33726.O842.13842.OO84O.9959.#726.33726.1718.8#728.85

Prefabricated ($75) 2 ($125) ComfortFit 1 ($300) 2 ($500) OrthoRepair ($50) Cervical Pillow

Cash Collected: $__________ Check Amount: $__________ #__________

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.