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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