Long Island City Pain Management & Rehabilitation Offices, P
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OFFICE NAME AND ADDRESS Comprehensive Exam and Treatment Order Patient’s Name: ______ID #: ______Date: ______Date of Birth: ______/______/______Age: ______Sex: M F MM WC NF/PI MCR LIEN CASH HISTORY OF PRESENT CONDITION(S)
PRIMARY/ASSOCIATED COMPLAINT(S) – Pain rating scale #1 - #10 with #10 being the worst pain Headache Right: ______ Left: ______ Hip Right Pain ___ Pain Scale # ___ Numb ______ Left Pain ___ Pain Scale # ___ Numb ______ Neck Right Pain ___ Pain Scale # ___ Numb ______ Left Pain ___ Pain Scale # ___ Numb ___ Knee Right Pain ___ Pain Scale # ___ Numb ______ Left Pain ___ Pain Scale # ___ Numb ______ Trapezius Right Pain ___ Pain Scale # ___ Numb ______ Left Pain ___ Pain Scale # ___ Numb ___ Ankle Right Pain ___ Pain Scale # ___ Numb ______ Left Pain ___ Pain Scale # ___ Numb ______ Shoulder Right Pain ___ Pain Scale # ___ Numb ______ Left Pain ___ Pain Scale # ___ Numb ___ Foot Right Pain ___ Pain Scale # ___ Numb ______ Left Pain ___ Pain Scale # ___ Numb ______ Elbow Right Pain ___ Pain Scale # ___ Numb ______ Left Pain ___ Pain Scale # ___ Numb ___ Toe(s) Right Pain ___ Pain Scale # ___ Numb ______ Left Pain ___ Pain Scale # ___ Numb ______List Digits: ______ Wrist Right Pain ___ Pain Scale # ___ Numb ______ Weakness Right: ______ Left: ______ Left Pain ___ Pain Scale # ___ Numb ___ UE: ______ LE: ______ Hand Right Pain ___ Pain Scale # ___ Numb ___ Coldness Right: ______ Left: ______ Left Pain ___ Pain Scale # ___ Numb ___ UE: ______ LE: ______ Finger(s) Right Pain ___ Pain Scale # ___ Numb ___ Burning Right: ______ Left: ______ Left Pain ___ Pain Scale # ___ Numb ___ UE: ______ LE: ______List Digits: ______ Mid-Back Right Pain ___ Pain Scale # ___ Numb ___ Tingling Right: ______ Left: ______ Left Pain ___ Pain Scale # ___ Numb ___ UE: ______ LE: ______ low Back Right Pain ___ Pain Scale # ___ Numb ___ Pain Right: ______ Left Pain ___ Pain Scale # ___ Numb ___ Radiating Left: ______To ______ Buttocks Right Pain ___ Pain Scale # ___ Numb ___ Other ______ Left Pain ___ Pain Scale # ___ Numb ______Patient’s Name: ______ID #: ______Date: ______ ALLERGIES No Allergies Allergic To:
MEDICATION Patient Denies Taking Any Medication Medications Taken:
REVIEW OF SYSTEMS
RESULTS OF PREVIOUS TREATMENT & TESTS PERFORMED None Describe:
SOCIAL/FAMILY MEDICAL HISTORY Heart Disease Stroke Circulatory Disorder Blood Pressure Diabetes Other:
HISTORY OF ACCIDENT
WORKER’S COMPENSATION QUESTIONS Date of Injury: Time: AM/PM Location (City and state where injury occurred): Did patient go to the hospital? Yes No Via: Ambulance Other (Indicate): Did patient suffer any cuts or contusions? Yes No (Describe) Is the patient working at the present time? Yes No Date last worked: Has the patient missed any time from work? Yes No Dates: At work patient is required to (in hours): Stand: Drive: Walk: Lift: Sit: Type: Other (Describe): What limitations does patient experience as a result of the injury? (circle affected area(s) below): Standing Driving Walking Lifting Sitting Typing Other (Describe): Further describe limitations: PERSONAL INJURY QUESTIONS Date of Injury: Time: AM/PM Was patient: Driver Passenger Front Seat Rear Seat Pedestrian Other
Was patient wearing seat belt? Yes No Did airbag deploy? Yes No Area of impact: Front Rear Passenger side Driver Side Other (Describe) Did patient go to the hospital? Yes No Via: Ambulance Other (Indicate): Did patient suffer any cuts or contusions? Yes No (Describe) X-rays taken? Yes No Region(s)
Fractures? Yes No Region(s)/Location(s)
Is the patient working at the present time? Yes No Date last worked: Has the patient missed any time from work? Yes No Dates: At work patient is required to (in hours): Stand: Drive: Walk: Lift: Sit: Type: Other (Describe): What limitations does patient experience as a result of the injury? (circle affected area(s) below): Standing Driving Walking Lifting Sitting Typing Other (Describe): Further describe limitations: Patient’s Name: ______ID #: ______Date: ______ PHYSICAL EXAMINATION – General CNS Visual Fields Height: ______Weight: ______Pulse: ______BP: ______ Within normal limits ______Patient is: Right handed Left handed Abnormal ______Heent: Within normal limits ______ Other ______ Other ______Nystagmus Chest: Within normal limits ______ Not present ______ CTA ______ Present ______ Other ______ Other ______Heart: S3 S4 Murmur ______Cranial Nerves S1 S2 No murmur ______ Within normal limits ______ Abnormal ______ Reg SR No Arrhythmia ______ Other ______ Other ______Fine Motor Abdomen: Soft No palpable viscera ______ Within normal limits ______ No heaptomegaly ______ Abnormal ______ Other ______ Other ______Extremities: Within normal limits ______Skin Cyanosis ______ Within normal limits ______ Clubbing ______ Abnormal ______ Edema ______ Other ______ Other ______ PHYSICAL EXAMINATION – General and Regional General Findings Neuritis ______ Tear of ______ Discoloration ______ Nodule/Mass/Cyst cm__ Area(s)______ Tendonitis ______ Ecchymosis ______Fibroma ______ Valsalva’s ______ Effusion/Swelling ______ Lipoma ______ Vascular Disease ______ Fracture of ______ Spasm ______ Weakness ______ Inflammation ______ Tenderness ______ Other ______ Myofascitis ______ Trigger Points ______Neck/Traps Wrist/Hand Hip Ranges of Motion: with pain Ranges of Motion: with pain Ranges of Motion: with pain Flexion _____/50 ______ Wrist Flexion R ___ L ___ (0-100) Extension _____/60 ______ Flexion R ___ L ___ (0-60) Extension R ___ L ___ (0-20) Right Rotation _____/80 ______ Extension R ___ L ___ (0-60) Internal Rotation R ___ L ___ (0-20) Left Rotation _____/80 ______ Ulnar Deviation R ___ L ___ (0-30) External Rotation R ___ L ___ (0-30) Right Lateral Flexion ______/45 _____ Radial Deviation R ___ L ___ (0-20) ABduction R ___ L ___ (0-25) Left Lateral Flexion ______/45 _____ ABduction R ___ L ___ (0-50) ADduction R ___ L ___ (0-15) Positive Orthopedic Findings: ADduction R ___ L ___ (0) Foraminal Compression R LSpurling’s R L Positive Orthopedic Findings: Positive Orthopedic Findings: Foraminal Distraction R L Jackson’s R L Bracelet R L Phalen’s Test R L Gaenslen’s R L Fabere-Patrick R L Shoulder Depressor R L Soto Hall R L Finkstein’s R L Reverse Phalen’s R L Ober’s R L Thomas’ Test R L Other ______ Ligament Thickening R L Other ______Shoulder Tinel’s Sign R L Knee Ranges of Motion: with pain Volar Deflection Soft Tissue Crowding Ranges of Motion: with pain Forward Flexion R ___ L ___ (0-180) Other ______Flexion R ___ L ___ (0-110) Backward Extension R ___ L ___ (0-50) Thoracic/Upper Trunk Extension R ___ L ___ (0) ABduction R ___ L ___ (0-170) Ranges of Motion: with pain Positive Orthopedic Findings: ADduction R ___ L ___ (0-40) Flexion _____/60 ______ ABduction Stress R L Lachman’s R L External Rotation R ___ L ___ (0-60) Right Rotation _____/30 ______ ADduction Stress R L McMurray R L Internal Rotation R ___ L ___ (0-80) Left Rotation _____/30 ______ Apley’s Compression R L Apley’s Distraction R L Positive Orthopedic Findings: Positive Orthopedic Findings: Patella Ballotment R L Patella Grinding R L Apley’s Scratch R L Scapular Winging R L Adams Soto Hall Drawer Test – Anterior R L Drawer Test - Posterior R L Codman Arm Drop R L Yeragson’s R L Schuppelmann’s Forester’s Valgus Stress R L Varus Stress R L Impingement Test R L Other ______ Other ______ Elbow Lumbar/Lower Trunk Other ______Ranges of Motion: with pain Ranges of Motion: with pain Ankle/Foot Ranges of Motion: with pain Flexion R ___ L ___ (0-140) Flexion _____/90 ______ Extension R ___ L ___ (0) Extension _____/25 ______Dorsiflexion R ___ L ___ (0-10) Plantar Flexion R ___ L ___ (0-20) Supination R ___ L ___ (0-70) Left Lateral Bending _____/25 ______Inversion R ___ L ___ (0-20) Eversion R ___ L ___ (0-10) Pronation R ___ L ___ (0-80) Right Lateral Bending _____/25 ______Foot ABduction R ___ L ___ (0-5) Positive Orthopedic Findings: Positive Orthopedic Findings: Positive Orthopedic Findings: Cozen’s R L Mill’s Test R L Belt Lasegue/SLR Ely’s Kemp’s Anterior Foot Drawer R L Epicondylitis R L Md Lt Braggard’s R___ L ___ Millgram’s Foot ADduction R L Golfer’s Elbow R L Tinel’s Sign R L Double SLR Nachlas Yeoman’s Other ______ Other ______ Other ______Patient’s Name: ______ID #: ______Date: ______MUSCLE TESTING Muscle Strength Rating System: x/5=Muscle Strength 0=Paralysis 1=No Movement/Minor Contraction 2=Movement w/no Gravity 3=Full ROM/Perceptible Weakness 4=Full ROM/Moderate Resistance 5=Full ROM/Maximum Strength Forearm Intrinsic Calf Ext Hallicus Deltoid Triceps Biceps Quadriceps Hamstrings Muscles Musc/Hand Muscles Longus R L R L R L R L R L R L R L R L R L Muscle Strength /5 /5 /5 /5 /5 /5 /5 /5 /5 /5 /5 /5 /5 /5 /5 /5 /5 /5 Muscle Atrophy Muscle Atrophy Rating System: P=Present A=Absent GRIP STRENGTH (Dynometer) R L R L R L (lbs)
DEEP TENDON REFLEXES 0=absent Brachio- Triceps Biceps Patella Achilles 1+=diminished Radialis 2+=normal R L R L R L R L R L 3+=hyper-reflexic 4+=pathological
BABINSKI Absent Present DERMATOMES Check all that apply: C5 C6 C7 C8 T1 R L R L R L R L R L Hyperesthesi GAIT Normal Abnormal Waddling a Trendelenberg Antalgic: Rt Lt Forward Hypoesthesia Heel Walk ______ Toe Walk ______ DIAGNOSTICNormal TESTING ORDERED CT Scan L1 L2 L3 ROM L4 L5 S1 RADIOLOGY Area(s) ______R L R L R L CervicalR ______L R L R L X-Ray Interp If Taken Elsewhere ______HyperesthesiArea(s) ______ Shoulder ______ Spine, Entire(6 view cervical, 2 view thoracic, 4 MRI Elbow ______view lumbar) ______Area(s)a ______ Wrist ______ Bilat Wrist/Hand (Total 6 views) ______HypoesthesiaArea(s) ______ Lumbar ______ Spine, Entire (AP&L) ______EMG/NCVNormal COMPLETE STUDY Hip ______ Cervical (AP&L) ______ Upper Extremity ______ Knee ______ Cervical (min. 4 view) ______ Lower Extremity ______ Ankle ______ Cervical, Complete (Davis Series) ______SSEP CMT Thoracic (AP&L) ______ Upper Extremity ______ Cervical ______ Thoracic (Comp. w/ obliques) ______ Lower Extremity ______ Shoulder ______ Thoracic Lumbar (AP&L) ______SONOGRAM Elbow ______ Scoliosis Study ______ Neck & Bilateral Traps ______ Wrist ______ Lumbosacral (AP&L) ______ Shoulder, R & L ______ Lumbar ______ Lumbosacral (Comp. w/ obliques) ______ Elbow, R & L ______ Hip ______ Lumbosacral (min. 4 views) ______ Wrist, R & L ______ Knee ______ Pelvis (AP only) ______ Upper Trunk ______BONE SCAN Shoulder, 2 views Bilateral ______ Lower Trunk & Bil S.I. ______ Too Rule Out______ Humerus, 2 views Bilateral ______ Gluts/Piri/Troc ______BOME DENSITY Elbow, 2 views 3 views Bilateral Hip, R & L ______ Spine ______ Knee, R & L ______ Extremity ______ Forearm, 2 views Bilateral ______ Ankle, R & L ______VASCULAR STUDY Wrist, 2 views 3 views Bilateral ______ Non-inv. Study-Single Level-Bilat______ Hand, 2 views 3 views Bilateral ______ Non-inv. Study-Multiple Level-Bilat______ EKG/SPIROMETRY Fingers, 2 views Bilateral ______ EKG ______ Hip, 2 views Bilateral ______ Spirometry ______ Knee, 2 views 3 views Bilateral HIGH FREQUENCY TRANSCUTANEOUS ______NERVE STIMULATION (TCNS) Tibia/Fibula, 2 views Bilateral ______ Spine ______ Ankle, 2 views 3 views Bilateral ______ Extremity ______ Other: ______
Patient’s Name: ______ID #: ______Date: ______
TREAMENT Spinal Adjustments Lumbar Stabilization ______ Shoulder Pulley/Wheel ______ Biofeedback (Neuromus Re-education) ______ Manual Traction ______ Spray & Stretch ______ Cold Pack ______ after exercise/PT Massage ______ Strengthen ______ CTS Protocol ______ McKenzie Exercises ______ Stretch/ROM ______ Diathermy ______ Mobilization ______ Synvisc Injection ______ Electrical Muscle Stimulation ______ Myofascial Release ______ High Frequency TCNS ______ Exercise for Instability ______ Neuromuscular Re-Edu ______ TENS ______ Gait Training ______ OMT (Osteopathic Manipulative Th)______ Tennis/Golf Elbow Program ______ Home Exercise Program ______ with Premanipulative Prep ______ Theraband Exercises ______ Hot Pack ______ after exercise/PT Paraffin Bath ______ Treadmill ______ Injection Type ______ Phonophoresis ______ UBE (Upper Body Exer.) ______Area(s) ______ Physio Ball Exercises ______ Ultrasound ______ Infrared ______ Plantar Fasciti/Heel Spur Protocol ______ Whirlpool ______ Iontophoresis ______ PRE (Progressive Resistive Exercise) ______ LBE (Lower Body Exer) ______ Rotator Cuff Foundation Exer. ______ Other ______ Lower Body Weight Training ______ Scapular & Cervical Strength ______ PROGNOSIS GUARDED POOR GOOD EXCELLENT FREQUENCY OF CARE & TREATMENT GOALS FREQUENCY: ______times per week for ______week then re-evaluate
TREATMENT GOALS: Decrease Pain Increase ROM Decrease Inflammation Strengthen Decrease Spasm Increase Endurance Improve Gait Reduce Trigger Points Increase Flexibility Sport-specific Strengthening SUPPORTS AND DEVICES PRESCRIBED Ankle, Air Cast Walking Splint ______ Finger, Spica Splint ______ Orthotic Initial Instruction ______ Ankle Brace w/ magnets ______ Hand Exercise/Pulley ______ Orthotic Follow-up Instruction ______ Arm Sling ______ Heel Cup ______ TENS Unit ______ Cervical Collar Custom ______ Hot/Cold Pack, Reusable ______ TENS Unit Initial Instruction ______ Cervical Traction for Home ______ Knee, Neoprene Brace w/ magnets ______ Wrist Cock-up Molded Splint w/ magnets ___ Cervical Pillow ______ Lumbar Support Custom ______ Other: ______ Crutches Cane ______ Lumbar Support Elastic Type w/ magnets ______ Elbow, Epicondyle Strap w/ magnets ______ Lumbar Seat Cushion ______ Elbow Brace w/ magnets ______ Orthotic w/ magnets ______ REFER TO WORK STATUS Orthopedist ______DISABILITY: PARTIAL TOTAL Neurologist ______WORKING: YES NO FULL TIME PART TIME Speech/Language Pathologist ______RESTICTIONS: ______ Chiropractor ______Patient Initials ______ Other ______ PRESCRIPTIONS: ______ DISABILITY STATUS / ADDITIONAL NOTES: ______
Doctor’s Signature: ______DOCTOR NAME Date: ______INSTRUCTIONS
1. By Federal Guidelines, you must re-evaluate your patient every 30 days…
2. This needs to be customized to your practice by modifying the heading on page 1 with your name and clinic information
3. When doing range of motions…I have given you the normal ranges based upon the AMA Guides to the Evaluation of Permanent Impairment 5th Edition, do not list numbers if you are doing a manual/visual range of motion…simply list N for normal and R for restricted.
4. I have kept this document very conservative to be accepted in every forum utilizing accepted nomenclature for every health professional. Different professions have specific nomenclature. It is my suggestion to use this standard and if necessary supplement your specific nomenclature, not substitute. There must be universally accepted standards in addition to any specific work you do with your patient.