Chiropractic Exam Form [PDF]

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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

1

2 LITTLE

3

4

5 MEDIUM

6

7

8 SEVERE

9

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 Spurling’s Shoulder Depression Libman’s Burn’s Bench Hoover’s Bechterew Beevor’s Minor’s Sign Ely Fajersztajn Nachlas Gluteal Punch Goldthwaite Heel-toe Walk Kemps Lasague Braggards Supported Adam’s

L

R

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 ______________________