PROVIDER/CLINIC NAME______________________________________________________________________________

DATE OF VISIT ___/___/20___

Check All that Apply:

Patient____________________________________________ DOB________________

_____NEW PATIENT _____ RE-EVALUATION _____ NEW CONDITION _____ ROUTINE VISIT

FOR INITIAL EXAM OR NEW CONDITION, Please give first date you noticed symptoms ____________________________
FOR INITIAL EXAM OR NEW CONDITION, What is your major complaint? _______________________________________

SUBJECTIVE PAIN ASSESSMENT

Right

RATE YOUR PAIN

Left

Place an X on the drawings

to the left wherever you
have pain. Beside the X
indicate the type of pain you
are experiencing:
Back

Front

A=Ache
B=Burning
ST=Stabbing
SP=Spasm
N=Numbness
P=Pins and Needles
T=Throbbing
(Example: XST between
your shoulders mean you
have stabbing pain between
your shoulders)

PAIN SCALE: Please circle the number that best describes your overall pain:
0
NONE

2
LITTLE

5
MEDIUM

8
SEVERE

10

10+
EXCRUCIATING

PATIENT/LEGAL GUARDIAN SIGNATURE__________________________________________________________

Doctor/Provider Signature _____________________________________________________________________

PROVIDER/CLINIC NAME _____________________________________________________________________

DATE OF VISIT ___/___/20___

Patient____________________________________________ DOB_______

Check ONE: _____INITIAL EXAMINATION _____ RE-EVALUATION

C0
DATE
C1

_____ NEW CONDITION

USING ARROWS

ASYMMETRY

TISSUE ABNORMALITIES
Mark the Misaligned
Vertebrae

C2
C3

T1

C4

T2

C5

T3

A _______
B _______
C _______

T4

C6
C7

T5

D _______

T6

E _______

T7

F _______

T8

G _______

L1
L2
L3

T9

L4

H _______

T10

L5

T11

SAC

T12

I _______

Mark Tissue Abnormalities: TP=Trigger Points, LG=Ligaments

(Swollen/Tender), TN=Tendons, SK=Skin, FS=Fascial Restrictions,
SP=Spasm, TI=Tightness

L-IL
R-IL
RANGE OF MOTION ASSESSMENT
CERVICAL

NORMAL

Flexion

PAIN

LUMBAR

NORMAL

50

Flexion

60

Extension

60

Extension

25

Left Lat Flex

45

Left Lat Flex

25

Right Lat Flex

45

Right Lat Flex

25

Left Rotation

80

Left Rotation

30

Right Rotation

80

Right Rotation

30

PAIN

Doctor/Provider Signature _____________________________________________________________________

PROVIDER/CLINIC NAME _____________________________________________________________________

DATE OF VISIT ___/___/20___

Patient____________________________________________ DOB_______

Check ONE: _____INITIAL EXAMINATION _____ RE-EVALUATION

_____ NEW CONDITION

EXAMINATION
B/P: __________ PULSE: __________ RESP: __________ HT: __________WT: _________ GRIP: (L)______ (R)______

REFLEXES (Wexler Scale)

SENSORY: C5:______ C6:______ C7:______ C8:______ T1:______ L3:______

Biceps _____________

L4:______L5:______ S1:______

D=Deficit N=Normal

(L) or (R)

Triceps _____________

GENERAL ORTHO/NEURO EXAMINATION: (+) or (-), (L) or (R)

Brac/rad ____________
Spinous Percus: _________

Babinski __________ Brudzinski __________

Dejerine Triad __________

Rhomberg__________ Valsalva____________

(+)

INDICATION

Patella _____________
Achilles ____________
TEST

(-)

Distraction
Jackson
Max Cerv Root Compression
Cervical Compression
Soto Hall
Spurlings
Shoulder Depression
Libmans
Burns Bench
Hoovers
Bechterew
Beevors
Minors Sign
Ely
Fajersztajn
Nachlas
Gluteal Punch
Goldthwaite
Heel-toe Walk
Kemps
Lasague
Braggards
Supported Adams

Nerve Root Compression

Nerve Root Compression
Nerve Root Compression
Nerve Root Compression
(cerv) (thor) Vertebral Trauma
Nerve Root Irritation
Nerve Root Compression
(low) (normal) (high) Pain Threshold
(hysteria) (Malingering)
(hysterical paralysis) (Malingering)
Sciatic Disc Compression
Abdominal Muscle Weakness
Radicular Disc Pain
Upper Lumbar Lesion
Intervertebral Disc Syndrome
Upper Lumbar Lesion
Spinal Lesion
Lumbar Differentiation
5th Lumbar Motor Deficit
Intervetebral Disc Rupture
(Muscle) (Disc) (Nerve) Irritation
Lumbar Antalgic Spasm
Lumbosacral Differentiation

MUSCLE TESTS
LEVEL
C5
C6
C7

C8

Muscle
Deltoids
Biceps
Wrist Extensors
Triceps
Wrist Flexors
Finger Extensors
Finger Flexors

Muscle Grade
L:
R;
L:
R:
L:
R:
L:
R:
L:
R:
L:
R:
L:
R:

LEVEL
T1
L2-L3
L4-L5
L3-L4
L5-S1
L4-L5
S1-S2

Muscle
Finger Abductors
Hip Flexors
Hip Extensors
Knee Extensors
KneeFlexors
Ankle Extensors
Ankle Flexors

Muscle Grade
L:
R:
L:
R:
L:
R:
L:
R:
L:
R:
L:
R:
L:
R:

DIAGNOSIS: _________________________________________________________________________________
___________________________________________________________________________________________
DOCTOR SIGNATURE
______________________________________________________

DATE
______________________