history_exam
History
Due to
Insidious Onset
Trauma
Work Injury
Personal Injury
Auto Collision
Areas involved
Right
Left
Neck
Mid Back
Low Back
Shoulder
Elbow
Hand
Hip
Knee
Foot
Radiating to
Right
Left
Shoulder
Arm
Hip
Leg
Radiating to other
Describe symtoms
Constant
Intermittent
Dull Ache
Sharp
Burning
Pain severity
1
2
3
4
5
6
7
8
9
10
Associated symptoms
Pain with
Cough
Sneeze
Deep Breath
Baring Down
Describe pain
Worse
Bending
Sitting Rising
Turning Neck
Turning Trunk
Turning Lower Back
Standing
Lying
Resting
AM
PM
No Effect
Worse other
Better
Bending
Sitting Rising
Turning Neck
Turning Trunk
Turning Lower Back
Standing
Lying
Resting
AM
PM
No Effect
Better other
Pain effected
NA
Job
Home
Recreational Activities
Effected other
Previous history
No
Yes
Previous history explain
Previous treatment
DC
MD
PT
Previous treatment other
Current treatment
DC
MD
PT
Current treatment other
Recent scans
X-Rays
MRI
CT
Scan location
Medications
NSAIDS
Muscle Relaxer
Medications other
Vitamins supplements
Mulivitamin
Calcium
Fish Oil
Vitamins supplements other
Recent or major surgeries
Current or past health problems
Family history of major illness
Musculosketal Exam
Constitutional
Ht
Wt
Bp
General appearance
Normal
Other
General appearance other
Current symptoms
Cervical
Thoracic
Lumbar
SI
Other
Symptoms other
Mechanical MecKenzie Exam
Cervical
Cervical wnl
Thoracic
Thoracic wnl
Lumbar
Lumbar wnl
Cerv rom
Subject
Object
WNL
Cerv flexion rom
Cerv flexion pain
Cerv flexion response
Cerv extension rom
Cerv extension pain
Cerv extension response
Cerv lt lat flex rom
Cerv lt lat flex pain
Cerv lt lat flex response
Cerv rt lat flex rom
Cerv rt lat flex pain
Cerv rt lat flex response
Cerv lt rotation rom
Cerv lt rotation pain
Cerv lt rotation response
Cerv rt rotation rom
Cerv rt rotation pain
Cerv rt rotation response
Thor rom
Subject
Object
WNL
Thor flexion rom
Thor flexion pain
Thor flexion response
Thor extension rom
Thor extension pain
Thor extension response
Thor lt lat flex rom
Thor lt lat flex pain
Thor lt lat flex response
Thor rt lat flex rom
Thor rt lat flex pain
Thor rt lat flex response
Thor lt rotation rom
Thor lt rotation pain
Thor lt rotation response
Thor rt rotation rom
Thor rt rotation pain
Thor rt rotation response
Lumb rom
Subject
Object
WNL
Lumb flexion rom
Lumb flexion pain
Lumb flexion response
Lumb extension rom
Lumb extension pain
Lumb extension response
Lumb lt lat flex rom
Lumb lt lat flex pain
Lumb lt lat flex response
Lumb rt lat flex rom
Lumb rt lat flex pain
Lumb rt lat flex response
Lumb lt rotation rom
Lumb lt rotation pain
Lumb lt rotation response
Lumb rt rotation rom
Lumb rt rotation pain
Lumb rt rotation response
Orthopedic Neurological
Cervical test
Lt cervical comp
Negative
Positive
Lt cervical comp response
Rt cervical comp
Negative
Positive
Rt cervical comp response
Soto hall
Negative
Positive
Soto hall response
Lt shoulder depression
Negative
Positive
Lt shoulder depression response
Rt shoulder depression
Negative
Positive
Rt shoulder depression response
Ditraction test
Negative
Positive
Ditraction test response
Extremity other
Negative
Positive
Extremity other response
Lumbar test
Left slr
Negative
Positive
Left slr response
Right slr
Negative
Positive
Right slr response
Lt braggards
Negative
Positive
Lt braggards response
Rt braggards
Negative
Positive
Rt braggards response
Lt patricks faber
Negative
Positive
Lt patricks faber response
Rt patricks faber
Negative
Positive
Rt patricks faber response
Lt elys
Negative
Positive
Lt elys response
Rt elys
Negative
Positive
Rt elys response
Milgrams
Negative
Positive
Milgrams response
Lt yeomans
Negative
Positive
Lt yeomans response
Rt yeomans
Negative
Positive
Rt yeomans response
Palpatory Tenderness
Oc c1
Left
Right
C1 c2
Left
Right
C2 c3
Left
Right
C3 c4
Left
Right
C4 c5
Left
Right
C5 c6
Left
Right
C6 c7
Left
Right
C7 t1
Left
Right
T1 t2
Left
Right
T2 t3
Left
Right
T3 t4
Left
Right
T4 t5
Left
Right
T5 t6
Left
Right
T6 t7
Left
Right
T7 t8
Left
Right
T8 t9
Left
Right
T9 t10
Left
Right
T10 t11
Left
Right
T11 t12
Left
Right
T12 l1
Left
Right
L1 l2
Left
Right
L2 l3
Left
Right
L3 l4
Left
Right
L4 l5
Left
Right
L5 si
Left
Right
Si
Left
Right
Reflexes
Bicep left
Increase
Decrease
Within Normal
Bicep right
Increase
Decrease
Within Normal
Brachio left
Increase
Decrease
Within Normal
Brachio right
Increase
Decrease
Within Normal
Tricep left
Increase
Decrease
Within Normal
Tricep right
Increase
Decrease
Within Normal
Patellar left
Increase
Decrease
Within Normal
Patellar right
Increase
Decrease
Within Normal
Achilles left
Increase
Decrease
Within Normal
Achilles right
Increase
Decrease
Within Normal
Vbi
Negative
Positive
Neurology
C5 motor
Increase
Decrease
Within Normal
C5 sensation
Increase
Decrease
Within Normal
C6 motor
Increase
Decrease
Within Normal
C6 sensation
Increase
Decrease
Within Normal
C7 motor
Increase
Decrease
Within Normal
C7 sensation
Increase
Decrease
Within Normal
C8 motor
Increase
Decrease
Within Normal
C8 sensation
Increase
Decrease
Within Normal
T1 motor
Increase
Decrease
Within Normal
T1 sensation
Increase
Decrease
Within Normal
L4 motor
Increase
Decrease
Within Normal
L4 sensation
Increase
Decrease
Within Normal
L5 motor
Increase
Decrease
Within Normal
L5 sensation
Increase
Decrease
Within Normal
S1 motor
Increase
Decrease
Within Normal
S1 sensation
Increase
Decrease
Within Normal
Coordination sensation
Increase
Decrease
Within Normal
Muscle testing
Cerv flex strgth
0
1
2
3
4
5
Cerv flex tone
Increase
Decrease
Within Normal
Cerv flex spasm
Cerv flex pain
Increase
Decrease
Within Normal
Scm strgth
0
1
2
3
4
5
Scm tone
Increase
Decrease
Within Normal
Scm spasm
Scm pain
Increase
Decrease
Within Normal
Upper trap strgth
0
1
2
3
4
5
Upper trap tone
Increase
Decrease
Within Normal
Upper trap spasm
Upper trap pain
Increase
Decrease
Within Normal
Mid trap strgth
0
1
2
3
4
5
Mid trap tone
Increase
Decrease
Within Normal
Mid trap spasm
Mid trap pain
Increase
Decrease
Within Normal
Lower trap strgth
0
1
2
3
4
5
Lower trap tone
Increase
Decrease
Within Normal
Lower trap spasm
Lower trap pain
Increase
Decrease
Within Normal
Scalenes strgth
0
1
2
3
4
5
Scalenes tone
Increase
Decrease
Within Normal
Scalenes spasm
Scalenes pain
Increase
Decrease
Within Normal
Subscap strgth
0
1
2
3
4
5
Subscap tone
Increase
Decrease
Within Normal
Subscap spasm
Subscap pain
Increase
Decrease
Within Normal
Supraspin strgth
0
1
2
3
4
5
Supraspin tone
Increase
Decrease
Within Normal
Supraspin spasm
Supraspin pain
Increase
Decrease
Within Normal
Teres strgth
0
1
2
3
4
5
Teres tone
Increase
Decrease
Within Normal
Teres spasm
Teres pain
Increase
Decrease
Within Normal
Quadriceps strgth
0
1
2
3
4
5
Quadriceps tone
Increase
Decrease
Within Normal
Quadriceps spasm
Quadriceps pain
Increase
Decrease
Within Normal
Psoas strgth
0
1
2
3
4
5
Psoas tone
Increase
Decrease
Within Normal
Psoas spasm
Psoas pain
Increase
Decrease
Within Normal
Tfl strgth
0
1
2
3
4
5
Tfl tone
Increase
Decrease
Within Normal
Tfl spasm
Tfl pain
Increase
Decrease
Within Normal
Piriformis strgth
0
1
2
3
4
5
Piriformis tone
Increase
Decrease
Within Normal
Piriformis spasm
Piriformis pain
Increase
Decrease
Within Normal
Gluteus strgth
0
1
2
3
4
5
Gluteus tone
Increase
Decrease
Within Normal
Gluteus spasm
Gluteus pain
Increase
Decrease
Within Normal
Hamstring strgth
0
1
2
3
4
5
Hamstring tone
Increase
Decrease
Within Normal
Hamstring spasm
Hamstring pain
Increase
Decrease
Within Normal
Quad lum strgth
0
1
2
3
4
5
Quad lum tone
Increase
Decrease
Within Normal
Quad lum spasm
Quad lum pain
Increase
Decrease
Within Normal
Lat dorsi strgth
0
1
2
3
4
5
Lat dorsi tone
Increase
Decrease
Within Normal
Lat dorsi spasm
Lat dorsi pain
Increase
Decrease
Within Normal
Infrspinatus strgth
0
1
2
3
4
5
Infrspinatus tone
Increase
Decrease
Within Normal
Infrspinatus spasm
Infrspinatus pain
Increase
Decrease
Within Normal
Diagnosis
Cervical
Thoracic
Lumbar
SI
Dysfunction
Strain Ligamentous Injury
Muscle Spasms
Diagnosis other
Treatment plan
Manual Manipulation
Manual Therapy Massage
Exercise Prescription
Treatment plan other
Frequency
4-8 Tx
12-15 Tx Then Re-Exam
PRN Flare-Up
Frequency other