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 LSpurling’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.