I CHIROFIT-1 623.773.2000

ti) NECK EXAM

ROM NORMAL EXAM NOTES:

Flexion 50

Extension 60

L. Rot. 80

R.Rot. 80

L. Lat. Flex 45

R. Lat. Flex 45

NECK ORTHOPEDIC TESTS Valsalva L R

Soto Hall L R

Cerv Compress L R

Cerv Distraction L R

Max Cerv Comp L R

Shoulder Depress L R

George's L R

f) � LOW BACK EXAM"

ROM NORMAL EXAM NOTES:

Flexion 60

Extension 25

L. Rot. 20

R.Rot. 20

L. Lat. Flex 25

R. Lat. Flex 25

LOW BACK ORTHOPEDIC TESTS

Elys L R

Kemp's L R

Nachlas L R

Yeomans L R

Braggard's L R

Minors Sign L R

Faber Patrick L R

BL Leg Raise L R

Single Leg Raise L R

Bechterew's Test L R

Heel Walk L R

Toe Walk L R

Dejerine Triad L R

Notes,

Notes,

PATIENT NAME:

MISC FINDINGS INITIAL DIAGNOSIS

0 SEE DIAGNOSIS PAGE

D Initial Exam 99203

D Re-Eval 99213

CHIROPRACTOR NAME

DATE

PHYSICAL1 NEUROLOGICAL1

& ORTHOPEDIC EXAM

0cc

C1

C2

C3

C4

cs

C6

C7

T3 _ _ _ _ _

T4 _ _ _ _ _ _

TS _ _ _ _ _

T6 _ _ _ _ _

L1

L2

L4

LS

S/Ps

Coccyx

Sleep Sitting Bending Working

Walking Standing Lifting Recreation

DATE:

HEIGHT:

WEIGHT: lbs

AGE:

BLOOD PRESSURE: I IMIHG

PULSE: lll'M

SENSORY IPINWHEEl/COTTON):

UPPER:

LOWER:

REFLEXES S=Sustained Clonus 4=Clonus 3=Hyper

2=Normal l=Diminished O=Absent

Biceps C5·6 L c:::::J R c:::::J Triceps C6-7 L c:::::J Rc:::::J Radial C6-7-8 -T1 L c:::::J Rc:::::J Patellar L2-3-4 L c:::::J Rc:::::J Achilles LS-51-2 L c:::::J Rc:::::J

MUSCLE TESTING S=Normal 4=Good 3=Fair 2=Poor

l=Trace O=NoContraction

Deltoid Wrist Ext Wrist Flex Quad Hamstring Ext Hal Lon

L c:::::J R c:::::J L c:::::J R c:::::J L c:::::J R c:::::J L c:::::J R c:::::J L c:::::J R c:::::J L c:::::J R c:::::J

.Attention .Memory ½

Dizziness Apathy

Headache Fatigue 3f?

Anxiousness Insomnia Change in Personality

PTSD&ASD

Flashbacks Nightmares Exposure Distress

Avoidance Behavior

Anger Insomnia

Hypervigilance Irritability 2/s

• Concentration

CHIROPRACTOR SIGNATURE