Advanced Chiropractic, P
REPORT OF FINDINGS
TREATMENT PLAN
PHASE I [ACUTE] PHASE II [SUBACUTE]
Start ___ / ___ / ___ Start ___ / ___ / ___
Duration _________ (2-4 weeks) Duration _________ (4 weeks)
Frequency _________ (2-3 times per week) Frequency _________ (1-2 times per week)
Goals Goals
Reduce pain/symptoms ______% (50-75%) Reduce pain/symptoms ______% (75-100%)
Decrease muscular spasm Improve ROM ______% (75-100%)
Improve ROM ______% (25-50%) Transition passive to active care rehabilitation
Treatment Treatment
( Spinal Adjustment ( Spinal Adjustment
( Extremity Adjustment ( Extremity Adjustment
( Joint Mobilization ( Joint Mobilization
( Intersegmental Traction ( Intersegmental Traction
( Myofascial Release ( Myofascial Release
( Trigger Point Therapy ( Mirror-Image Adjustment
( AROM / Stretching ( Manual Traction
( Other _______________ ( Proprioception Exercises
( Other _______________ ( Isometric Exercises
( Other _______________ ( Other ______________
( Other _______________ ( Other ______________
Current Dx: ________________________ Current Dx: ______________________
___________________________________ _________________________________
Notes: _____________________________ Notes: ___________________________
___________________________________ _________________________________
PHASE III [REHABILITATIVE] PHASE IV [MAINTENANCE]
Start ___ / ___ / ___ Start ___ / ___ / ___
Duration _________ (4-8 weeks) Duration _________ (4 weeks +)
Frequency _________ (1 times per week) Frequency _________ (1-4 times per month / PRN)
Goals Goals
Strengthen & Support Postural/Functional Weaknesses Maintain Improved Function
Improve Functional Stability Maintain Pain-free Status
Posture & Saggital Curve Correction Sustain Corrections Achieved During Phase III Care
ADL / Function Improvement ___________________ Prevent Deterioration of Function
Treatment Treatment
( Spinal Adjustment ( Spinal Adjustment
( Extremity Adjustment ( Extremity Adjustment
( Joint Mobilization ( Joint Mobilization
( Intersegmental Traction ( Mirror-Image Adjustment
( Mechanical Traction ( Intersegmental Traction ( Myofascial Release ( Manual Traction
( Isotonic Strengthening ( Other _____________
( Therapeutic Activities ( Other _____________
( Cardio/Elliptical (Warm-up)
( Other _______________
Current Dx: _________________________________________________________________________________
Notes: ____________________________________________________________________________
_________________________________________________________________________________
-----------------------
Reason for seeking chiropractic care:
1. _______________________________________________________________________________
2. _______________________________________________________________________________
3. _______________________________________________________________________________
4. _______________________________________________________________________________
Functional deficits & impaired activities of daily living:
1. _______________________________________________________________________________
2. _______________________________________________________________________________
3. _______________________________________________________________________________
4. _______________________________________________________________________________
5. _______________________________________________________________________________
Prior macro & micro traumas correlated to current problem(s):
1. _______________________________________________________________________________
2. _______________________________________________________________________________
3. _______________________________________________________________________________
4. _______________________________________________________________________________
5. _______________________________________________________________________________
Significant examination findings:
_____ Restricted Ranges of Motion _____ Muscular Weakness _____ Abnormal DTR
_____ Abnormal Posture _____ Trigger Points _____ Positive Orthopedic Tests
_____ Joint Complex Dysfunction _____ Myofascial Instability _____ Numbness
_____ Weight Distribution >5 lbs. _____ Asymmetric Contract _____ Tingling / Paresthesia
_____ Abnormal Gait _____ Palpatory Tenderness _____ Paralysis
_____ Asymmetric Dynanometry _____ Referred Pain _____ Abnormal Dermatomes
Significant X-ray findings:
1. ________________________________________________________________________________
2. ________________________________________________________________________________
3. ________________________________________________________________________________
4. ________________________________________________________________________________
5. ________________________________________________________________________________
................
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