Patient Daily Visit Notes
Date: / / Visit of
Subjective
Overall condition (since last office visit):
← significantly improved
← slightly improved
← not changed
← slightly worsened
← significantly worsened
Subjective Complaint Key: 0 = Pain Free, 5 = Moderate, 10 = Sever Pain
Headache Occipital Frontal Temporal
L R L R L R
Neck Pain Stiffness Paresthesia Spasm
L R L R L R L R
Upper Pain Stiffness Paresthesia Spasm
Back L R L R L R L R
Midback Pain Stiffness Paresthesia Spasm
L R L R L R L R
Lowback Pain Stiffness Paresthesia Spasm
L R L R L R L R
Upper Ext Pain Stiffness Paresthesia Spasm
L R L R L R L R
Lower Ext Pain Stiffness Paresthesia Spasm
L R L R L R L R
Activities of Daily Living
( Within Normal Limits ( Unchanged
( Increased ( Decreased
Objective
Fluid Motion Left Right Even
Short Leg Left Right Even
Cervical Syndrome Left Right Negative
Derefield Positive Negative Balanced
Sacral Leg Left Right Negative
Myofascial Hypertonicity
Key: 1 = Minimal, 2 = Mild, 3 = Mild to Moderate,
4 = Moderate, 5 = Moderate to Severe, 6 = Severe
Suboccipital Thoracic Lumbosacral
L R L R L R
Cervical Upper Trap Upper LS-sp
L R L R L R
Mid Cervical Mid Scapular Lower LS-sp
L R L R L R
Lwr Cervical Lower Trap Gluteal
L R L R L R
Range of Motion Global Segmental Both
Level of Restriction Key: 1 = Minimal, 2 = Mild, 3 = Mild to Moderate,
4 = Moderate, 5 = Moderate to Severe, 6 = Severe
Cercical Thoracic Lumbosacral
L R L R L R
( All unmarked exams unremarkable
Orthopedic Tests
Key: L=Positive Left, R=Positive Right, B=Positive Bilateral, N=Negative, NP=Not Performed
Foraminal Comp. Nachlas Yoeman’s Kemp’s
L R L R L R L R
B B B B
N N N N
NP NP NP NP
Assessment
← improvement
← unchanged
← worsening
← exacerbation
Plan
Adjustments
|Palpation |Segment |Listing |Technique |
|Findings | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
Key: T=Taut & Tender, E= Edema, SF= Sudoriferous Changes,
HT= Hypertonicity.TP= Trigger Points, F= Fixation, HM= Hypermobility
( Heat ( Cold
( Home Instruction
Ice Therapy
Stretch / Exercise Program
( Continue Care Plan ( Modify Care Plan
( R/S Re-examination ( Discharge
( Referral for Further Evaluation
ICD-9
CPT
E/M
Date: / / Visit of
Subjective
Overall condition (since last office visit):
← significantly improved
← slightly improved
← not changed
← slightly worsened
← significantly worsened
Subjective Complaint Key: 0 = Pain Free, 5 = Moderate, 10 = Sever Pain
Headache Occipital Frontal Temporal
L R L R L R
Neck Pain Stiffness Paresthesia Spasm
L R L R L R L R
Upper Pain Stiffness Paresthesia Spasm
Back L R L R L R L R
Midback Pain Stiffness Paresthesia Spasm
L R L R L R L R
Lowback Pain Stiffness Paresthesia Spasm
L R L R L R L R
Upper Ext Pain Stiffness Paresthesia Spasm
L R L R L R L R
Lower Ext Pain Stiffness Paresthesia Spasm
L R L R L R L R
Activities of Daily Living
( Within Normal Limits ( Unchanged
( Increased ( Decreased
Objective
Fluid Motion Left Right Even
Short Leg Left Right Even
Cervical Syndrome Left Right Negative
Derefield Positive Negative Balanced
Sacral Leg Left Right Negative
Myofascial Hypertonicity
(Key: 1 = Minimal, 2 = Mild, 3 = Mild to Moderate,
4 = Moderate, 5 = Moderate to Severe, 6 = Severe)
Suboccipital Thoracic Lumbosacral
L R L R L R
Cervical Upper Trap Upper LS-sp
L R L R L R
Mid Cervical Mid Scapular Lower LS-sp
L R L R L R
Lwr Cervical Lower Trap Gluteal
L R L R L R
Range of Motion Global Segmental Both
(Level of Restriction Key: 1 = Minimal, 2 = Mild, 3 = Mild to Moderate,
4 = Moderate, 5 = Moderate to Severe, 6 = Severe)
Cercical Thoracic Lumbosacral
L R L R L R
( All unmarked exams unremarkable
Orthopedic Tests
Key: L=Positive Left, R=Positive Right, B=Positive Bilateral, N=Negative, NP=Not Performed
Foraminal Comp. Nachlas Yoeman’s Kemp’s
L R L R L R L R
B B B B
N N N N
NP NP NP NP
Assessment
← improvement
← unchanged
← worsening
← exacerbation
Plan
Adjustments
|Palpation |Segment |Listing |Technique |
|Findings | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
Key: T=Taut & Tender, E= Edema, SF= Sudoriferous Changes,
HT= Hypertonicity.TP= Trigger Points, F= Fixation, HM= Hypermobility
( Heat ( Cold
( Home Instruction
Ice Therapy
Stretch / Exercise Program
( Continue Care Plan ( Modify Care Plan
( R/S Re-examination ( Discharge
( Referral for Further Evaluation
ICD-9
CPT
E/M
................
................
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