i chirofit-1 physical & orthopedic exam · i chirofit-1 623.773.2000 ti) neck exam rom normal...

I CHIROFIT-1 623.773.2000 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 GE D Initial Exam 99203 D Re-Eval 99213 CHIROPRACTOR NAME DATE PHYSICAL 1 NEUROLOGICAL 1 & ORTHOPEDIC EM 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: M SENSORY IPINWHEECOON): UPPER: LOWER: REFLEXES S=Sustained Clonus 4=Clonus 3=Hyper 2=Normal l=Diminished O=Absent Biceps C5·6 L R Triceps C6-7 L R Radial C6-7- 8- T1 L R Patellar L2-3-4 L R Achilles LS-51-2 L R 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 R L R L R L R L R L R .Attention .Memory ½ Dizziness Apathy Headache Fatigue 3 Anxiousness Insomnia Change in Personality PTSD&ASD Flashbacks Nightmares Exposure Distress Avoidance Behavior Anger Insomnia Hypervigilance Irritability 2/s • Concentration CHIROPRACTOR SIGNATURE

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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,

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

T3 _ _ _ _ _

T4 _ _ _ _ _ _

TS _ _ _ _ _

T6 _ _ _ _ _

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