SAMPLE FORMS FOR DOCUMENTATION Documentation 2011 Page Book # # SUBJECTIVE ______1. Auto accident Fill-in History Form ------5-7 2. History Form ------8 667 a. Qualitative vs. quantitative ------9 421 2. Past Medical and Family History form ------10 668 3. ------11 669 4. Expanded History Form ------12 5. Red-Flag Questionnaires (2 versions) and the AHCPR stats on accuracy------13-15

OBJECTIVE

6. Tenderness Scale ------16 165 7. forms 17/19 a. Cervical ------17-18 670-71 b. Lumbar ------19-20 672-73 8. Waddell Signs (see lumbar exam form for documentation) ------614-19 9. QFCE forms ------22-24 312-30 a. Strength and endurance normative data (Alaranta tests) 26 155-62 b. Horizontal Side Bridge normative data 27 c. Grip & pinch normative data (Jamar data) 28 d. & e. 3-minute step test norms (men - b, woman - c) 29 f. 3-minute step test - instructions 28 ______ASSESSMENT

10. ASSESSMENT (see the “A” or pg 2 of the PE forms) 30 648-50 a. Psychosocial Yellow Flags ------403-4 1. Biopsychosocial Model 439-43

30 652-59 b. Goal Setting ------671/73 PLAN _____ 11. PLAN / Procedures ------31-32 649-50 12. PT Log form ------33 660-61 13. Route slip 676-77 a. Example ------34-35 14. Functional Capacity Testing (discussion only*; bolded items include a form) a. Occupational Therapist referral* b. Job Demands Questionnaire ------36-37 646-47 c. Lift / Carry tests (i.e., EPIC, PILE)* Ch 17 d. Spinal Function Sort*------345-49 e. Quantitative Functional Capacity Evaluation (QFCE) ------312-32 (Text: Alaranta Chap 12) 155-62 (Text: Appendix QFCE Forms) 614-17 f. Static Position Tolerance Tests* 636-37

1

g. Return to Work form ------38 675

DAILY SOAP NOTES 39 664-65 15. Daily Notes examples ------40 666 16. Abbreviations of SOAP note form ------

Documentation of X-ray Findings 41 674 16. Elements ------

a. Introductory information

b. Report

c. Template

d. Example

Re-Evaluations (Discussion only)

17. Progress notes

 Reevaluations

 Reexaminations  counseling and/or coordination of care

Chapter 2 18. Mechanisms of Documentation a. Dictation and transcription (Discussion: e-mail service option) b. Computer-assisted record keeping [commercial programs] c. Word processing programs 42-43 1. Macros: see examples and the table of contents for a disc ------2. Boilerplate text 664-65 d. Hand-written notes (39-40) 666 1. see SOAP forms ------Chaps Chapter 3 5-10 19. Outcome Assessment Measurement Devices & 15 a. Pain 1. Quadruple VAS (QVAS) ------44 511 2. Pain drawing ------45 421-22 b. General Health 1. HSQ-12 and scoring template ------46-51 501-06 c. Condition-specific 1. Disability Index (HDI) ------52 539 2. Oswestry Low Back Disability Questionnaire (OLBDQ) ------53 515 3. Disability Index (NDI) ------54 537 4. Scoring method for Oswestry & NDI ------55 2

5. Global Impression of Change ------56 6. Back Bournemouth Questionnaire (BBQ) ------57 7. Neck Bournemouth Questionnaire (NBQ ------58 8. Patient Specific Functional And Pain Scales ------59

564 d. Patient satisfaction 60 1. Satisfaction Questionnaire ------560 e. Psychometric Ch 10 1. Beck's Depression Inventory ------61-62 + 21 f. Disability prediction 651-57 1. Yellow Flags Q (1st visit and Re-exam forms; scoring method) -..- 63-64 644 g. Outcomes Score Card (clean copy and completed example) ------65-66

i. PT Log ------67 660-61

Miscellaneous 662 20. Patient intake information ------68 a. Insurance information

b. Vitamin//orthotic log 69

663 21. Photocopying log ------

70-73 22. UE & LE Functional Scales ------

74-77 406 23. Business Associate Agreement (NEW Mandated by 2-17-2010 ------

78 24. Informed Consent ------

79-80 491- 25. Appendix Forms CD ------679

81 26. New Forms CD ------

81 27. Recommended publications

a. Order form for The Chiropractic Report (Special bonus) ------

b. Discussion and other recommended publications------82-83

28. CareTrak software 84 a. Description ------406 b. SAMPLE: CareTrak brief form tracking outcomes------

29. Outcomes Assessment supplies (SGY)

a. Table of Contents text: Clinical Application of Outcomes 85-86 Assessment, ed. SGY ------

b. Order form (includes a description of available materials) ------87-90 3

SUBJECTIVE AUTOMOBILE ACCIDENT QUESTIONNAIRE

SELECT FROM THE FOLLOWING LIST ALL THAT APPLY:

______STOPPED/SLOWING DOWN FOR (TRAFFIC/RED LIGHT/STOP SIGN) AND WAS STRUCK IN THE REAR BY ANOTHER VEHICLE.

______WAS PUSHED INTO THE VEHICLE IN FRONT OF HIS/HERS.

______SLOWING DOWN TO EXECUTE A TURN AND WAS STRUCK IN THE REAR BY ANOTHER VEHICLE.

______WAS SIDE SWIPED BY ANOTHER VEHICLE TRAVELING IN THE SAME DIRECTION.

______ANOTHER VEHICLE TRAVELING IN THE OPPOSITE DIRECTION COLLIDED HEAD- ON WITH THE VEHICLE IN WHICH (HE/SHE) WAS RIDING.

______ANOTHER VEHICLE RAN A (RED LIGHT/STOP SIGN) AND STRUCK (HIS/HER) VEHICLE (BROADSIDE/IN THE REAR/IN THE FRONT END).

______THE VEHICLE IN WHICH (HE/SHE) WAS RIDING WAS STRUCK BY ANOTHER VEHICLE CAUSING IT TO (SPIN AROUND/ROLL OVER).

______THE PATIENT WAS INVOLVED IN A MULTI-CAR COLLISION.

______THE PATIENT WAS INVOLVED IN A MOTOR VEHICLE COLLISION.

______THE DRIVER OF THE VEHICLE IN WHICH (HE/SHE) WAS RIDING LOST CONTROL AND (STRUCK ANOTHER VEHICLE/RAN OFF THE ROAD/STRUCK AN OBJECT).

DESCRIBE______

______THE PATIENT WAS THROWN FROM THE CAR TO THE PAVEMENT.

______THE PATIENT INJURED (HIS/HER) BACK IN A LIFTING ACCIDENT.

______OTHER(BRIEF DESCRIPTION):______

4 ______WAS THE PATIENT WEARING A SEAT BELT? ____YES ____NO (If Yes, circle: Lap, Chest, Both )

SELECT FROM THE FOLLOWING LIST ANY OBJECT WHICH THE PATIENT'S BODY STRUCK AT THE POINT OF IMPACT?

____HEAD ____FACE ____CHEST ____NECK ____BACK

____SHOULDER(S) RIGHT/LEFT ____ARM(S) RIGHT/LEFT

____LEG(S) RIGHT/LEFT ____KNEE(S) RIGHT/LEFT

SELECT THE OBJECTS THAT WERE STRUCK:

____WINDSHIELD ____HEADREST ____DASHBOARD

____STEERING COLUMN ____DOOR FRAME ____BACK OF SEAT

____REAR VIEW MIRROR ____SEAT BROKE ____JARRED OR THROWN

____CANNOT REMEMBER DETAILS (DAZED) ____RENDERED UNCONSCIOUS

____OTHER:______

IF THE PATIENT HAS BEEN TREATED BY ANY OTHER PHYSICIANS FOR NECK OR BACK PROBLEMS, PLEASE EXPLAIN:______

IF APPLICABLE, INDICATE ANY PAINS OR ABNORMAL SENSATIONS EXPERIENCED BY THE PATIENT IMMEDIATELY FOLLOWING THE IMPACT:

____HEADACHE ____"SAW STARS" ____SEMI CONSCIOUS STATE

____NECK PAIN-RIGHT/LEFT ____MID-BACK PAIN-RIGHT/LEFT

____LOW BACK PAIN-RIGHT/LEFT ____UPPER EXTREMITY PAIN- RIGHT/LEFT ____LOWER EXTREMITY PAIN-RIGHT/LEFT

____OTHER______

INDICATE ANY ACTION TAKEN BY THE PATIENT IMMEDIATELY FOLLOWING THE ACCIDENT:

____WENT HOME AND TOOK IT EASY ____WENT ABOUT NORMAL BUSINESS

____WENT TO PHYSICIAN ____WENT TO HOSPITAL

5 ____PATIENT DOCTORED HIMSELF/HERSELF THINKING PAIN WOULD GO AWAY

HOSPITALIZATION --INDICATE METHOD OF DELIVERY TO HOSPITAL:

____AMBULANCE ____PATIENT DROVE HIMSELF/HERSELF

____DRIVEN BY SPOUSE/RELATIVE/FRIEND

____WENT HOME AND TAKEN LATER OR DROVE HIM/HERSELF TO HOSPITAL

NAME OF HOSPITAL:______

CITY:______STATE:______ZIP:______

WAS THE PATIENT SEEN IN THE EMERGENCY ROOM? ____YES ____NO

LENGTH OF STAY: ______

NAME (IF KNOWN) OF ADMITTING PHYSICIAN: ______

INDICATE ANY PROCEDURE PERFORMED AT THE HOSPITAL (INCLUDING THE EMERGENCY ROOM):

____EXAMINATION ____X-RAYS ____PRESCRIPTION

____INJECTION ____STITCHES ____PHYSIOTHERAPY

____CERVICAL COLLAR ____WOUNDS DRESSED ____COMPLETE BED REST

____OTHER______

WHAT WERE YOU TOLD WAS WRONG WITH YOU? ______

WHAT WERE YOU TOLD TO DO FOR FOLLOW-UP CARE? ______

WHO WAS THE FIRST PHYSICIAN YOU CONSULTED? DR.______

____FAMILY PHYSICIAN ____CHIROPRACTOR ____ORTHOPEDIST

____OSTEOPATH ____NEUROLOGIST ____WALK-IN-CLINIC

____OTHER______

6

CHECK OR CIRCLE THE SIGNIFICANT ITEMS THAT APPLY IN YOUR CASE:

Increased risk Decreased risk

Small target vehicle (struck vehicle) Wet or icy road conditions. Large bullet vehicle (strike vehicle) Target vehicle is moving at time of impact. Dry pavement Brakes are not on. Brakes were locked (target vehicle stopped) Automatic transmission in struck vehicle. Manual transmission (your car / other car) Seat belts (at high speeds) Increased seat rebound Awareness of impact (bracing) Seatbelts (worn at low speeds?) Proper headrest position Female gender Tall / slender (ectomorphic phenotype) Children Unawareness of impact Poor head restraint position (>2 inches away) Head restraint too low (< midpoint occip) Head rotation at time of impact Elderly . 65 yo (gradual ↑ risk @ > 40 yo) Pre-existing health conditions (circle or check)  Often pre-MVA asymptomatic (usually, no pre-collision pain)  Disc degeneration (x-ray or MRI/CT?)  Spinal degeneration ()  Prior spinal  Osteoporosis (fracture?)  Metabolic disorders (eg. Thyroid )  Rheumatic disorders (eg., Rh. Arthritis)  Primary or metastatic (cancer)  infection

7

CONSULTATION / HISTORY

IN: ______DATE OF ACCIDENT______OUT: ______DOCTOR______DATE OF EXAM______DICTATION DATE______

NAME______AGE______BIRTH DATE______ADDRESS______WORK PHONE______HOME PHONE______CITY______STATE______ZIP______SEX: M F MARITAL STATUS______SPOUSE NAME______NO. OF CHILDREN______DRIVER'S LICENSE #______S.S. #______OCCUPATION______YEARS______EMPLOYER______

ACCIDENT/TRAUMA HISTORY (SEE ENCLOSED WC, PI, POLICE REPORT) ______

CHIEF COMPLAINT 1.______ONSET______PAIN(PROVOCATIVE)______(PALLIATIVE)______QUALITY______RADIATION/LOCATION______SEVERITY (VAS): Now: ______; Ave.: _____; Min. to Max.: - /10 TIMING: AM > < PM; Mon > < Fri. ______FREQUENCY: Intermittent / Constant DURATION______SPECIAL______

2.______ONSET______PAIN(PROVOCATIVE)______(PALLIATIVE)______QUALITY______RADIATION/LOCATION______SEVERITY (VAS): Now: ______; Ave.: _____; Min. to Max.: - /10 TIMING: AM > < PM; Mon > < Fri. ______FREQUENCY: Intermittent / Constant DURATION______SPECIAL______

3.______ONSET______PAIN(PROVOCATIVE)______(PALLIATIVE)______QUALITY______RADIATION/LOCATION______SEVERITY (VAS): Now: ______; Ave.: _____; Min. to Max.: - /10 TIMING: AM > < PM; Mon > < Fri. ______FREQUENCY: Intermittent / Constant DURATION______SPECIAL______

4.______ONSET______PAIN(PROVOCATIVE)______(PALLIATIVE)______QUALITY______RADIATION/LOCATION______SEVERITY (VAS): Now: ______; Ave.: _____; Min. to Max.: - /10 TIMING: AM > < PM; Mon > < Fri. ______FREQUENCY: Intermittent / Constant DURATION______SPECIAL______8 ______

Quantitative vs. qualitative - documentation methods

Clinical Qualitative Chart Note Quantitative Chart Note Attribute Onset The patient presented The patient presented with the insidious onset of lower back pain of with a sub-acute history an 8 day duration and reports progressively worsening symptoms. of lower back pain. Palliative Improved with rest and Improved with rest after 2 hours, or with 600 mg after 1 factors use of NSAIDs hour. Uses 600 mg ibuprofen q.i.d. without full resolve. Provocative Increased pain is noted Increased pain is noted upon standing > 15 min, sitting > 30 min, factors upon standing, sitting, driving > 45 min, or lifting >25 pounds. driving and lifting. Quality Burning, numbness, Burning, numbness, sharp, dull, tingling. (The quality of pain sharp, dull, tingling cannot be quantified!) Radiation Pain down R leg to mid- Pain down from R lower gluteal to R posterior leg to mid calf, calf ranges between 3-7/10. Pain severity The patient described The patient described LBP right now at 5/10, on average at 3/10, moderate LBP pain. and pain ranges between 2 and 8/10 Timing Pain in the back is Lower back pain over L5 area is intermittent, present approx. 50% intermittent. of waking hours. Previous Patient stated that he has Patient stated that he has periodic episodes of lower back pain, episodes had previous lower back approx. 3x year, each lasting for approx. 2 weeks, with pain 3-6/10. pain, usually resolved Usually resolved without treatment. without treatment.

The history can "tell a story" by quantifying the items gathered. ALWAYS try to place a unit of measure on each historical item so that "medical necessity" for ongoing care can be justified by the history.

9

NAME: ______DATE:______

PAST HISTORY

PREVIOUS (MVA, WC, etc.)______

PREVIOUS TREATMENT HISTORY DATE DR/HOSP TREATMENT RESPONSE TREATMENT TEST(S) TEST (G, NG, NChnge) DURATION RESULT

PAST HOSPITALIZATIONS / ILLNESS______SURGICAL HISTORY______GENERAL STATE OF HEALTH______MEDICATIONS/VITAMINS______ALLERGIES______IMMUNIZATIONS ______

FAMILY HISTORY [1. FATHER, 2. MOTHER, 3. SISTER (a, b, etc), 4. BROTHER (a, b, etc.)] CANCER ( )______DIABETES ( )______; CARDIAC ( )______; CVA ( )______; BP ( )______; EPILEPSY ( )______; TB ( )______OTHER______

PSYCHO-SOCIAL HISTORY OCCUPATIONAL DATE OCCUPATION WC CLAIMS DISABILITIES ENJOYED

Activities of Daily Living (Changes as a result of : ______RECREATIONAL/EXERCISE: Type: ______Freq. ____/wk; Duration _____ Min. / Hrs;______

SOCIAL HISTORY MARITAL STATUS (Circle): Single, Married, Divorced, Widowed EDUCATIONAL LEVEL: < High School; H.S. Grad.; College (yrs:___) Degree: _____; Tech. (yrs___) Dipl.: ____ SOCIAL HABITS (Please circle appropriate responses and fill in the blank) TOBACCO: ___ pk / ___day, wk, for ___ yrs; Chew ___ yrs; Pipe___ yrs CAFFEINE (SODA, COFFEE, TEA) ______/ day ALCOHOL ____ glasses of wine, beer, mixed dr. / day, wk, mo.; SLEEP INTERRUPTED? ____ x’s / night for ____ mo, yrs WORK ROUTINE ABLE RESTRICTED UNABLE Sit in office chair 1 2 3 4 5 Stand concrete 1 2 3 4 5 Climb steps / stairs 1 2 3 4 5 Stoop to retrieve 1 2 3 4 5 Crouch to retrieve 1 2 3 4 5 Kneel to retrieve 1 2 3 4 5 Reach overhead 1 2 3 4 5 Lift waist to shoulder 1 2 3 4 5 Carry 100 feet 1 2 3 4 5 Push 1 2 3 4 5 Pull 1 2 3 4 5 Balance 1 2 3 4 5 Crawl 1 2 3 4 5 Reach 1 2 3 4 5 Handling 1 2 3 4 5 Fingering 1 2 3 4 5

10

NAME: ______DATE:______

REVIEW OF SYSTEMS

Please write in a number: 1. PRESENTLY HAVE; 2. PREVIOUSLY HAD; 3. RELATED TO ACCIDENT (Date: ______)

GENERAL MUSCULOSKELETAL CARDIOVASCULAR ___Allergy ___Arthritis ___Hardening of arteries ___Chills ___Bursitis ___High ___Convulsions ___Foot Trouble ___Low blood pressure ___Dizziness ___Hernia ___Pain over heart ___Fainting ___Low back pain ___Poor circulation ___Fatigue ___Lumbago ___Rapid heart beat ___Fever ___Neck pain/stiffness ___Slow heart beat ___Headache ___Shoulder blade pain ___Swelling of ankles ___Sleep loss Pain or numbness in: RESPIRATORY ___Weight loss ___ Shoulders ___Chest pain ___Nervousness/depression ___ Arms ___Chronic cough ___Neuralgia ___ ___Difficult breathing ___Numbness ___ Hands ___Spitting up blood ___Sweats ___ Hips ___Spitting up phlegm ___Tremors ___ Legs ___Wheezing EYES, EARS, NOSE, THROAT ___ Knees GASTROINTESTINAL ___Asthma ___ Feet ___Belching or gas ___Colds ___Painful tailbone ___Colitis ___Sore throat ___Poor posture ___Colon trouble ___Deafness ___Sciatica ___Constipation ___Dental decay ___Spinal curvature ___Diarrhea ___Earache/noises GENITO-URINARY ___Difficult digestion ___Ear discharge ___Bedwetting ___Distention of abdomen ___Sinus infection ___Blood in urine ___Excessive hunger ___Enlarged glands ___Frequent urination ___Gall bladder trouble ___Enlarged thyroid ___Inability to control bladder ___Hemorrhoids ___Nose bleeds ___Kidney infection or stones ___Intestinal worms ___Failing vision ___Painful urination ___Jaundice ___Far sighted ___Prostate trouble ___Liver trouble ___Gum trouble ___Pus in urine ___Nausea ___Hay fever ___Painful menstruation ___Pain over stomach ___Hoarseness ___Hot flashes ___Poor appetite ___Nasal obstruction ___Irregular cycle ___Vomiting ___Near sighted ___Lumps in breasts ___Vomiting blood

OTHER:______

11

EXPANDED HISTORY FORM Clinic name ______

Name ______DOB / Age______Date ______

Since your motor vehicle accident or personal injury of ______(date):

1. Please list all the doctors, locations, therapy type and response to the therapy in order, starting at the date of your accident / Injury.

Date Doctor’s name / Location Treatment (PT, DC, MD, Treatment Response Drugs, rehab, other)

2. List all activities or situations that worsens your pain (include duration of tolerance; example “sitting >15 minutes.” Separate home - H and work - W activities): ______

3. Please list all activities that you have had to stop, modify or change as a result of your work- related or personal injury (S = stopped; M = modified; C = changed): ______

4. Please explain how the injury affected your personal, social or occupational lifestyle (Relationships, hobbies sports, work, etc.): ______

12

Red Flags: AHCPR, (Bigos, 1994) Check-off list:

CANCER

 History of cancer  Unexplained weight loss  Pain not improved with rest  Age > 50  Failure to respond to a course of conservative care (4 weeks)  LBP > 4 weeks

INFECTION

 Prolonged use of corticosteroids (such as organ transplant Rx)  Intravenous drug use  Urinary tract, respiratory tract or other infection  Immunosuppression medication &/or condition

SPINAL FRACTURE

 History of significant trauma  Minor trauma in person >50 years old or osteoporotic  Age >70 years old  Prolonged use of corticosteroids

CAUDA EQUINA

 Acute onset urinary retention or overflow incontinence  Loss of anal sphincter tone or fecal incontinence  Saddle anesthesia  Global or progressive motor weakness in lower limbs

COMMENTS:______

NAME ______DATE ______AGE _____

13

RED FLAG QUESTIONNAIRE

NAME ______DATE ______AGE _____

Please check the appropriate response. If "yes", please explain. If you are not sure, check the "?" box. THANK YOU!

NO YES ?    Do you have a past history of cancer?    Have you had any unexplained weight loss?    Does your pain improve with rest?    Are you over 50 years old?    Failure to respond to a course of conservative care (4-6 weeks)?    Have you had spinal pain greater than 4 weeks?

NO YES ?    Prolonged use of corticosteroids (such as organ transplant Rx)?    Intravenous drug use?    Current or recent urinary tract, respiratory tract or other infection?    Immunosuppression medication &/or condition?

NO YES ?    History of significant trauma?    Minor trauma in person >50 years old?    Do you have osteoporosis (weak )?    Are you over 70 years old?    Any history of prolonged use of corticosteroids?

NO YES ?    Acute onset urinary retention or overflow incontinence (wet underwear)    Loss of anal sphincter tone or fecal incontinence (bowel accidents)    Saddle anesthesia (numbness in the groin region)    Global or progressive muscle weakness in the legs (legs give out)

COMMENTS:______

14

AHCPR Red-Flag chart

Estimated accuracy of in diagnosis of spine causing low back problems

References Disease to be Medical history red flags True-positive rate True negative rate detected (sensitivity) (specificity) Deyo and Diehl Cancer Age >/= to 50 0.77 0.71 Previous cancer history 0.31 0.98 Unexplained weight loss 0.15 0.94 Failure to improve with 1 month of 0.31 0.90 therapy Bed rest no relief >0.90 0.46 Duration of pain 0.50 0.81 >1 month Age >/= 50 or Hx of cancer or 1.00 0.60 unexplained weight loss or failure of conservative therapy Waldvogel and Spinal Intravenous drug abuse, UTI, or skin 0.40 NA Vasey Osteomyelitis infection Unpublished data Compression Age >/= 50 0.84 0.61 (a) Fracture Age >/=70 0.22 0.96 Trauma 0.30 0.85 Corticosteroid use 0.06 0.995 Deyo and Tsui- Herniated Sciatica 0.95 0.88 Wu; Spangfort disc Turner, Ersek, Spinal Pseudoclaudication 0.60 NA Herron, et al. Stenosis Gran Ankylosing Age>/= 50 0.90 b 0.70 spondylitis Positive responses 4 out of 5 0.23 0.82 Age at onset /=3 months 0.71 0.54 a From 833 with back pain at a walk-in clinic as reported in Deyo, Rainville, and Kent (3). Al received plain lumbar roentgenograms. b Author's estimate.

1. Deyo RA, Tsui-Wu YJ. Descriptive epidemiology of low-back pain and its related medical care in the United States. Spine 1987 Apr;12(3):264-8. 2. Deyo RA, Diehl AK. Cancer as a cause of back pain: frequency, clinical presentation, and diagnostic strategies. J Gen Intern Med 1988. 3. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA 1992 Aug 12;268(6):760-5. 4. Gran JT. An epidemiology survey of the of ankylosing spondylitis. Clin Rheumatol 1985 Jun;4(2):161-9. 5. Spangfort EV. The lumbar disc herniation. Acta Orth Scand (Suppl) 1972;142:1-95. 6. Turner JA, Ersek M, Herron L, Deyo R. Surgery for lumbar . Attempted meta-analysis of the literature. Spine 1992;17:1-8.

15

OBJECTIVE

Grading Soft tissue pain objectively

SOFT TISSUE TENDERNESS GRADING SCHEME (Hubbard, et al.) Grade I mild tenderness to moderate * Grade II moderate tenderness with grimace &/or flinch to moderate palpation. Grade III severe tenderness with withdrawal (+"Jump Sign") Grade IV severe tenderness with withdrawal (+jump sign) to non-noxious stimuli (i.e. superficial palpation, pin prick, gentle )**

*Moderate palpation = 4 kg pressure (to the point the palpating finger nail blanches) ** In non-injured tissue, this is a sign of neuropathic pain.

16

CERVICAL SPINE PHYSICAL EXAM

Name______Date______DOI______(LEFT/RIGHT)

L R 1. Brachial B.P: Lt______/______Rt______/______Pulse______Respirations ______Height______Weight______Temperature______Age______

2. OBSERVATION Posture______Gait______(Pronated; Supinated) Other______

3. PALPATION Spasm,TP's, Pain: Cerv______Dors______Lum______SIJ (L/R)______Temp______Mankopf: _____ to _____ b/m @ TP______/4 Abdomen Murphy’s, R / L UQ; R / L LQ: ______Rectal______Chest/Breast______Other (masses, thyroid, lymph nodes, , capillary filling, trophic changes) ______

4. ROM (active, active assisted and/or passive) (visual, inclinometer, other:______) Cervical Exam Pain Location/ /  pain = +1;  pain = -1 Quality (0-4 Grade) Peripheralize = +2; Centralize = -2 Flexion _____ / 50 0-1-2-3-4 sharp / dull / pull Extension _____ / 63 0-1-2-3-4 sharp / dull / pull L Lat Flex _____ / 45 0-1-2-3-4 sharp / dull / pull R Lat Flex _____ / 45 0-1-2-3-4 sharp / dull / pull L Rot. _____ / 85 0-1-2-3-4 sharp / dull / pull R Rot. _____ / 85 0-1-2-3-4 sharp / dull / pull

5. ORTHOPEDIC EXAMINATION Cervical L R Findings L R Findings Cerv. Distraction TOS: Adson Max. Cerv. Rot.Comp. Rev.Adson Vert./Basiler Insuff. Costoclav. Shoulder Depression Wright Drop Arm Wrist: Tinel’s Ext. Rot (P.A.R.) Phalen Int. Rot. (P.A.R.) Rev Phalen Mill / Cozen Med.N.Tether t. Pron.T. (Compr/Tinel) DeQuervain Radial T (Compr/Tinel) CT Compression Cubital T (Compr/Tinel) Bakody's Sign

6. Level Motor test, [cord level, nerve] Motor Reflex [cord level] DTR Sensation Exam (1.Pin; 2.2-Pt; x/5 +/- Wexler 3.Vib; 4.Semmes-W) L R L R L R C5 Deltoid [C5 axillary n.] __/5 __/5 Biceps [C5, C6] C5 / Axillary n. Biceps [C5,6 musculocutaneous n] __/5 __/5 __/5 __/5 C6 Biceps [C5,6 musculocutaneous n] __/5 __/5 Brachioradialis [C6] C6 / Musculocut. n. Wrist Extensors [C6,7 radial n]rad=C6 __/5 __/5 __/5 __/5 uln=C7 C7 Triceps [C7 radial n.] __/5 __/5 Triceps [C7] C7 / Digit 3, palmar Wrist Flexors [C7 median/ulnar n] __/5 __/5 __/5 __/5 [variable] Finger Extenders [C7 radial n] __/5 __/5 C8 Finger Flexors [C8,T1 median/ulnar n] __/5 __/5 Wrst(C7,8); Uln(C8,1) __/5 __/5 C8 / Med antebr cut n. T1 Finger Abd/Add [T1 ulnar n] __/5 __/5 Ulnar (C8, T1) __/5 __/5 T1 / Med antebr cut n.

CN II-XII II: Fundus, III, IV, VI: "H", V: Corneal, light touch, mastication VIII: Rinne, Weber, X: Soft palate elev, larynx acuity, diplopia, ptosis, VII: Facial expression & Taste IX: XI: SCM, upper trap wnl fields PERRLA XII: Tongue Dev./Strength Vestibular: wnl Cerebellum: wnl D.Columns: wnl Cerebrum: wnl; S O M A Labrinth: wnl Pathological Babinski (Corticospinal tract) / UMN _____/_____ Clonus (L / R elb / knee) Spastic / flaccid Paralysis L / R UE / LE Grip / Pinch Strength Right hand: ( Pain induced Y / N ) Left hand: ( Pain induced Y / N ) Dominant L/R (Circle) 1st______kg/lbs; 2nd______kg/lbs; 3rd______kg/lbs 1st______kg/lbs; 2nd______kg/lbs; 3rd______kg/lbs

17 NAME______DATE______(Pg. 2 C-Spine Exam)

Shoulder Abd Add Flex Ext IR ER Scap Ele Scap Scap Ret Painful arc Pro Normal 180 75 180 60 90 90 Left Right MM Mid Delt, SS PecMaj, Lat Delt, Coracobr Lat, TeresMaj IS,TeresMin Subscap, Pect Trap, LevSc SerrAnt Rhom [2] Shoulder Test Exam Finding Test Exam Finding SS Tendonitis / SS tendonitis Yergason's/Speed's / Bicipital tendonitis Apley Scratch t. / Rot cuff tendonitis, ss Drawer, apprehension / Recurrent dislocation Drop Arm test / Rotator cuff tear Dawburns / Sub-AC bursitis

Elbow Flex Ext Sup Pro Normal 150 10 90 90 Left Right MM Brachialis, Biceps C5, 6 Triceps C7 Biceps C5, 6 supinator C6 Pronator teres C6 , Pronator quad C8-T1 Test Exam Finding Test Exam Finding Tinel (Ulnar T,PT) / Neuroma / N. compression Ligamentous instability / Med or lat collateral damage Cozen's t. / Lat. epicondylitis Golfer's elbow t. / Med. epicondylitis Mill's t. / Lat. epicondylitis Rev. Cozen's t. / Med. epicondylitis Med.N.Comp. t. / Pron.Teres L:___sec. / R:___sec. Radial Tunnel Compr. t. / Radial Nerve L:___ sec. / R:___ sec. Palp: Lat. / Med Epi., Rad Head , Olecranon , Cubital Tunnel Compr.t / Ulnar Nerve L:___ sec. / R:___ sec.

Wrist Flexion Extension Ulnar Deviation Radial Deviation Normal 80 70 30 20 Left Right MM FCR, FCU ECRL, ECRB, ECU FCU, ECU ECRB, ECRL, APL, EPB Wrist Test Exam Finding Test Exam Finding Phalen's / CTS L:___sec. / R:___sec. Tinel's / L = 1 2 3 4; R = 1 2 3 4 (Severity) Rev. Phalen's / CTS L:___sec. / R:___sec. Finkelstein's / Sten. tenosynovitis APL, EPB; / Med.N.Comp. t. / CTS L:___sec. / R:___sec. Allen's / Radial, ulnar a. occlusion Med.N.Tether t. / Stenosing tenosynovitis Flexor tendons Grip: L R Dominant L / R / / (lbs / kg) /

Assessment: (Circle: Mechanical, Nerve root, ); C-disc @ C-____ w/ o radiation above / below elbow; C-sprain / strain / myofascitis / myositis; Nerve root tether C-____; Torticollis L / R; Other: ______DD:______Complicating Factors: 1. Abnormal illness behavior; 2. Job dissatisfaction; 3. Past Hx of >4 episodes; 4. Symptoms > 1 wk; 5. Severe pain intensity; 6. New condition / injury related to pre-existing structural pathology or skeletal anomaly Goal Setting: Short-term Goals: Long-term Goals: 1. Decrease pain ______% in ______days. 1. Functional restoration. 2. Increase ROM ______% in ______days. 2. Initiate Active / Home care. 3. Decrease spasm in ______days. 3. Rehabilitation / Strengthening. 4. Return to work in ______days. 4. Education / "Back school". 5.______5. ______Plan: Therapy Frequency Remarks Chiro. manipulative therapy ______x/week x______weeks; Other Ice/heat 15 minute rotations: on / off / on x 3 (= 1.25 hr / session) Interferential mm. stim. Acute: 80-100 cps / 10 min.; Chronic: 0-10 cps / 15 min. Traction Cerv. long axis Office: ______Pounds / ______minutes Lumb. long axis Home: ______Pounds / ______minutes Intersegmental Exercises Acute: Isometric w/in pain boundaries Flexion Subacute: Isotonic, passive ROM to boundary, Extension Initiate proprioception retraining QFCE ______(date) Chronic: Evaluate functional status (QFCE) Work hardening Initiate isokinetic, progressive resistance MRI / CT / Bone scan X-R Lumbar, Thoracic, Cervical: Davis, 5-, 3-, 2-views Lab Blood Test______; Urine Test: UA, Culture, ___ Restrict activities: Work: Regular duty Work Light duty ADL's Total temporary disability: ______days, weeks, month Reeval for RTW ______days, weeks Progress reeval 1, 2, 3, 4, 6, weeks Referral to: Disability / impairment rating 18 LUMBAR SPINE PHYSICAL EXAM

Name______Date______DOA______(LEFT/RIGHT) 1. VITAL SIGNS L R Brachial B.P: Lt______/______Rt______/______Pulse______Respirations ______Height______Weight______Temperature______Age______2. OBSERVATION Posture______Gait______(Pronated; Supinated) Other______3. PALPATION Spasm,TP's, Pain: Cerv______Dors______Lum______SIJ (L/R)______Temp______Mankopf: Pulse _____ to _____ b/m @ TP______/4 Abdomen Murphy’s, R / L UQ; R / L LQ: ______Rectal______Chest/Breast______Other (masses, thyroid, lymph nodes, pulses, capillary filling, trophic changes) ______4. ROM (active, active assisted and/or passive) (visual, inclinometer, other:______) Lumbar Range of Motion Pain McKenzie Tests  pain = +1;  pain = -1 Quality (degrees) Location of complnt (0-4 Grade) Peripheralize = +2; No Change = 0; Centralize = -2 Flexion _____ / 65 0 1 2 3 4 FIS: 1 Rep: +2 +1, 0, -1 -2; 10 reps: +2 +1, 0, -1 -2 sharp / dull / pull Extension _____ / 30 0 1 2 3 4 EIS: 1 Rep: +2 +1, 0, -1 -2; 10 reps: +2 +1, 0, -1 -2 sharp / dull / pull L Lat Flex _____ / 25 0 1 2 3 4 Side Gliding: +2,+1, 0,-1,-2; Limited Y / N; Blocked Y / N sharp / dull / pull R Lat Flex _____ / 25 0 1 2 3 4 Side Gliding: +2,+1, 0,-1,-2; Limited Y / N; Blocked Y / N sharp / dull / pull

5. ORTHOPEDIC EXAM (Pain Scale 0-4; Centralize -1; Peripheralize = +1); OBJECTIVE: DD Mechanical LBP from Nerve Root Lumbar L R Findings Test L R Findings Facet: Nerve Tension: - / + - / + Kemp 0 1 2 3 4 0 1 2 3 4 Chin to chest= LBP 0 1 2 3 4 0 1 2 3 4 Double SLR 0 1 2 3 4 0 1 2 3 4 Supine SLR (A P) 0 1 2 3 4 0 1 2 3 4 _____/_____ (70) Sacroiliac: Foot DF + SLR 0 1 2 3 4 0 1 2 3 4 Yeoman 0 1 2 3 4 0 1 2 3 4 Hip IR + SLR 0 1 2 3 4 0 1 2 3 4 Hibb 0 1 2 3 4 0 1 2 3 4 Well-leg Raise 0 1 2 3 4 0 1 2 3 4 Motion palp. 0 1 2 3 4 0 1 2 3 4 Sitting SLR 0 1 2 3 4 0 1 2 3 4 Gaenslin’s 0 1 2 3 4 0 1 2 3 4 Bow String 0 1 2 3 4 0 1 2 3 4 Delitto (3 of 4 = +) 1. Standing Flexion PSIS 2. Sitting PSIS Slump Test 0 1 2 3 4 0 1 2 3 4 3. Supine to Long Sitting; 4. Prone Knee Flexion Compr. / Distrac. 0 1 2 3 4 0 1 2 3 4 Jugular vv compress. 0 1 2 3 4 0 1 2 3 4 Hip: Ext. Coord. LB LB Janda Trunk Flex 1.Incr. Lord. Y/N; 2.Foot press Dn: Y/N; 3.Scap Raise Y/N >G.Max >G.Max Hip Abduction Pass/Fail Pass/Fail _____/_____ Int. Rot (A P) 0 1 2 3 4 0 1 2 3 4 _____/_____ (45) P. Fabere 0 1 2 3 4 0 1 2 3 4 Ext. Rot (A P) 0 1 2 3 4 0 1 2 3 4 _____/_____ (43) Waddell Non-organic LBP signs: Score _____ / 5 3. Distraction: + “flip sign” 1. Superficial Pain 4. Regional Neurology. 2. Simulation Tests: Axial Cmpr; Trunk Rotation 5. Exaggeration

6. NEUROLOGICAL EXAMINATION: Red Flag: Rule out Nerve Root lesion Level Motor test: [cord level, nerve] Motor x/5 + / - Reflex [cord level] DTR (Wexler) Sensation Exam (1.Pin; 2.2-pt 3.Vib; 4.Semmes-W L R L R L R T12-L3 Iliopsoas -Hip Flexion [T12-L3] ____/5; ____/5 Cremasteric (L1,2) P / A P / A T12-L3 derm. L2-L4 Quadriceps - Knee Ext. [L3,4 femoral n.] Patellar [L2,L3, L4] L2-L4 Hip adductors [L2-4 obturator n.] ____/5; ____/5 ______/5; ______/5 dermatome L4 Tibialis Anterior [L4, deep peroneal n.] ____/5; ____/5 Patellar [L2,L3, L4] ______/5; ______/5 L4 dermatome L5 Ext Hall Long [L5, deep peroneal n.] Hamstring / (semitendinosis) L5 dermatome Ext Dig Long/Brev [L5, deep peroneal n.] ____/5; ____/5 [L4. L5, S1, 2] ______/5; ______/5 Gluteus Medius [L5, supr.glut.n.] S1 Peroneus Lng/Brev [L5,S1 sup.peroneal n] Achilles [S1] S1 dermatome Gastrocnemius-soleus [S1, inf. glut. n.] ____/5; ____/5 ______/5; ______/5 CN II-XII II: Fundus, III, IV, VI: "H", V: Corneal, light touch, mastication VIII: Rinne, Weber, nystagmus X: Soft palate elev, larynx acuity, fields diplopia, ptosis, VII: Facial expression & Taste IX: Dysphagia XI: SCM, upper trap wnl PERRLA XII: Tongue Dev./Strength Vestibular: wnl Cerebellum: wnl D.Columns: wnl Cerebrum: wnl; S O M A Labrinth: wnl Pathological Babinski (Corticospinal tract) / UMN _____/_____ Clonus (L / R elb / knee) Spastic / flaccid Paralysis L / R UE / LE Grip / Pinch Strength Right hand: ( Pain induced Y / N ) Left hand: ( Pain induced Y / N ) Dominant L/R (Circle) 1st______kg/lbs; 2nd______kg/lbs; 3rd______kg/lbs 1st______kg/lbs; 2nd______kg/lbs; 3rd______kg/lbs Circumference Upp Ext.: Brach. ______/______in. / cm (______" above elbow) AnteBr. ______/______in. / cm (______" below elbow) Chest: Insp_____ Exp_____ (_____ICS) Low Ext.: Thigh ______/______in. / cm (______" above Patella) Calf ______/______in. / cm (______" below patella)

19 NAME______DATE______(Pg. 2 L-spine Exam)

Hip Abduction Adduction Flexion Extention Internal Rotation External Rotation Norma 50 30 135 30 40 60 l Left Right MM Glut medius Adductor longus Iliopsoas Glut Max Adductor longus, brevis Glut max, obt. ext. Hip Test Exam Finding Test Exam Finding Fabere / Inflammatory hip Ober's t / TFL or tibial band contracture Trendelenberg / Glut med weakness [contralateral] Thomas t. / Hip flexor contracture Hibb's / SI vs. hip Psoas Contracture / Tight hip flexors

Knee Flex Ext IR ER Normal 135 0 10 10 Left Right MM Semimemb/tend/biceps Quad cannot be isolated cannot be isolated Knee Test Exam Finding Test Exam Finding McMurray / Posterior meniscus tear Varus/Valgus stress / Lat/med collateral lig Apley Distraction / Meniscus vs ligamentous lesion Ant/post draw signs / Ant/post cruciate lig Apley Compression / Medial vs. lateral meniscus tear Bounce home / Meniscus Patellar grinding / Chondromalacia pat/retropatellar OA Patella Battotement / Edema

Ankle Dorsiflexion Plantar flexion Inversion Eversion Normal 20 50 35 15 Left Right MM Tibialis ant, EDL, EHL Gastroc, Soleus, Plantaris Tibialis post, FDL, FHL Peronius,long, brev, tertius Ankle Test Exam Finding Test Exam Finding Ant/post Drawer / Ant/post talofibular lig Med/Lat stability t. / Ant talofibular/calcaneofibular lig Pronation / Pes Pl. / (w/ w/o metatarsalgia / loss) Supination / Tinel's / Ant. Tarsal Tunnel / Deep Peroneal n. Tinel's / Post. Tarsal Tunnel / Tibial n.

Assessment: (Circle: Mechanical, Nerve root, Pathology); L-disc @ L-____ w/ o radiation above / below knee; L-sprain / strain / myofascitis / myositis; SIJ sprain L / R; Hip - synovitis, arthritis, bursitis, ______Other: ______DD:______Complicating Factors: 1. Abnormal illness behavior; 2. Job dissatisfaction; 3. Past Hx of >4 episodes; 4. Symptoms > 1 wk; 5. Severe pain intensity; 6. New condition / injury related to pre-existing structural pathology or skeletal anomaly Goal Setting: Short-term Goals: Long-term Goals: 1. Decrease pain ______% in ______days. 1. Functional restoration. 2. Increase ROM ______% in ______days. 2. Initiate Active / Home care. 3. Decrease spasm in ______days. 3. Rehabilitation / Strengthening. 4. Return to work in ______days. 4. Education / "Back school". 5.______5. ______Plan: Therapy Frequency Remarks Chiro. manipulative therapy ______x/week x______weeks; Other Ice/heat 15 minute rotations: on / off / on x 3 (= 1.25 hr / session) Interferential mm. stim. Acute: 80-100 cps / 10 min.; Chronic: 0-10 cps / 15 min. Traction Cerv. long axis Office: ______Pounds / ______minutes Lumb. long axis Home: ______Pounds / ______minutes Intersegmental Exercises Acute: Isometric w/in pain boundaries Flexion Subacute: Isotonic, passive ROM to boundary, Extension Initiate proprioception retraining QFCE ______(date) Chronic: Evaluate functional status (QFCE) Work hardening Initiate isokinetic, progressive resistance MRI / CT / Bone scan X-R Lumbar, Thoracic, Cervical: Davis, 5-Series, 3-series, 2- series Lab Blood Test______; Urine Test: UA, Culture, _____ Restrict activities: Work: Regular duty Work Light duty ADL's Total temporary disability: ______days, weeks, month Reeval for RTW ______days, weeks Progress reeval 1, 2, 3, 4, 6, weeks Referral to: Disability / impairment rating

20

Estimated accuracy of physical examination for lumbar disc herniation among patients with sciatica

References Test True-positive True negative Comments rate rate (sensitivity) (specificity) Hakelius and Hindmarsh (1972); Ipsilateral SLR 0.80 0.40 Positive result: leg pain at <60 Kosteljanetz, Expersen, Halaburt (1984) Hakelius and Hindmarsh (1972) Crossed SLR 0.25 0.90 Positive result: reproduction of Spangfort (1972) contralateral pain Hakelius and Hindmarsh (1972) Ankle dorsiflexion 0.35 0.70 HNP usually at L4-L5 (80%) weakness Hakelius and Hindmarsh (1972) Great toe extensor 0.50 0.70 HNP usually at L5-S1 (60%) or Kortelainen, Puranen, Koivisto, weakness L4-L5 (30%) et al (1985) Hakelius and Hindmarsh (1972) Impaired ankle 0.50 0.60 HNP usually at L5-S1; absent Spangfort (1972) reflex reflex increases specificity Kortelainen, Puranen, Koivisto, Sensory loss 0.50 0.50 Area of loss poor predictor of et al (1985) HNP level Kosteljanetz, Expersen, Halaburt (1984) Aronson and Dunsmore (1963) Patellar reflex 0..50 NA For upper lumbar HNP only Hakelius and Hindmarsh (1972) Ankle plantar 0.06 0.95 _ flexion weakness Hakelius and Hindmarsh (1972) Quadriceps <0.01 0.99 - weakness Note: Sensitivity and specificity were calculated by Deyo, Rainville, and Kent (1). Values represent rounded averages where multiple references were available. All results are from surgical case series. HNP= herniated nucleus pulposus. SLR = Straight leg raising.

1. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA 1992 Aug 12;268(6):760-5. 2. Hakelius A, Hindmarsh J. The comparative reliability of preoperative diagnostic methods in lumbar disc surgery. Acta Orthop Scand 1972;43:234-8. 3. Kosteljanetz M, Expersen JO, Halaburt H, Miletic T. Predictive value of clinical and surgical findings in patients with lumbago- sciatica. A prospective study (Part I). Acta Neurochir (Wien) 1984;73(1-2):67-76. 4. Kortelainen P, Puranen J, Koivisto E, Lahde S. Symptoms and signs of sciatica and their relation to the localization of the lumbar disc herniation. Spine 1985;10:88-92. 5. Aronson HA, Dunsmore RH. Herniated upper lumbar discs. J Bone Surg [Am] 1963;45:311-7. 6. Spangfort EV. The lumbar disc herniation. Acta Orth Scand (Suppl) 1972;142:1-95.

Reprinted with permission from Bigos S, Bowyer O, Braen G, et al. Acute low back problems in adults. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and research, 1994

21

QUANTITATIVE FUNCTIONAL CAPACITY EVALUATION

NAME______DATE______DOB______DOI______TIME IN______Dx:______

TEST INITIAL 1st Re-exam 2nd Re-exam 3rd Re-exam Standing Date: Date: Date: Date: 1. Pre-Test VAS ______/10 ______/10 ______/10 ______/10 2. 3-minute Step Test (pulse) ______pre ______post- ____pre ______post- ______pre ______post- ______pre ______post- 3. ROM: PAIN SCALE: LUMBAR EXTREMITY (L/R) FLEXION (FORW.FLEX) FL _____ +2,1,0,-1,2 FL _____ +2,1,0,-1,2 FL _____ +2,1,0,-1,2 FL ______+2,1,0,-1,2 EXTENSION (BACKWARD EXT) EXT____ +2,1,0,-1,2 EXT____ +2,1,0,-1,2 EXT____ +2,1,0,-1,2 EXT______+2,1,0,-1,2 RT. LAT. FLEX (ABDUCTION) RLF____ +2,1,0,-1,2 RLF____ +2,1,0,-1,2 RLF____ +2,1,0,-1,2 RLF______+2,1,0,-1,2 LT. LAT. FLEX (ADDUCTION) LLF_____ +2,1,0,-1,2 LLF_____ +2,1,0,-1,2 LLF_____ +2,1,0,-1,2 LLF______+2,1,0,-1,2 4. PAIN (Superficial):Waddell #1 + / - + / - + / - + / - 5. SIMULATION: Waddell #2 a. Trunk Rotation + / - + / - + / - + / - b. Axial Compression (5 kg) + / - + / - + / - + / - TESTS L R L R L R L R 6. Horizontal Side Bridge Time/sec Time/sec Time/sec Time/sec Time/sec Time/sec Time/sec Time/sec

(record in seconds) ______7. Gastroc/Ankle DF (Knee extd) _____ _____ _____ _____ _____ _____ _____ _____ 8. Soleus/Ankle DF (Knee flexed) _____ _____ _____ _____ _____ _____ _____ _____ 9a.* One-Leg Stand (eyes open) ___Sec. ___Sec. ___Sec. ___Sec. ___Sec. ___Sec. ___Sec. ___Sec. 9b.* One-Leg Stand (eyes closed) ___Sec. ___Sec. ___Sec. ___Sec. ___Sec. ___Sec. ___Sec. ___Sec. 10. Exaggeration (Waddell #5) + / - + / - + / - + / - 11. Rep. Squat (feet 15cm apart)  Thigh horizontal, 1 rep/2-3 sec., ____ # of reps. ____ # of reps. ____ # of reps. ____ # of reps. note # of reps; max. reps 50;

Seated TESTS L R L R L R L R 12. Sitting SLR / DISTRACTION LBP: LBP:  LBP: LBP:  LBP:  LBP:  LBP:  LBP: (Waddell #3; see #13)  LBP: (circle) yes / no yes / no yes / no yes / no yes / no yes / no yes / no yes / no 13. Regional Neuro. (Waddell #4) + / - + / - + / - + / - + / - + / - + / - + / - 14. ROM: PAIN SCALE: CERVICAL EXTREMITY (L/R) FLEXION (FORW.FLEX) FL ______+2,1,0,-1,2 FL _____ +2,1,0,-1,2 FL ______+2,1,0,-1,2 FL ______+2,1,0,-1,2 EXTENSION (BACKWARD EXT) EXT____ +2,1,0,-1,2 EXT____ +2,1,0,-1,2 EXT_____ +2,1,0,-1,2 EXT______+2,1,0,-1,2 RT. LAT. FLEX (ABDUCTION) RLF_____ +2,1,0,-1,2 RLF____ +2,1,0,-1,2 RLF_____ +2,1,0,-1,2 RLF______+2,1,0,-1,2 LT. LAT. FLEX (ADDUCTION) LLF_____ +2,1,0,-1,2 LLF_____ +2,1,0,-1,2 LLF______+2,1,0,-1,2 LLF______+2,1,0,-1,2 RT. ROTATION (EXT. ROT.) RR _____+2,1,0,-1,2 RR _____+2,1,0,-1,2 RR ______+2,1,0,-1,2 RR ______+2,1,0,-1,2 LT. ROTATION (INT. ROT.) LR _____+2,1,0,-1,2 LR _____+2,1,0,-1,2 LR ______+2,1,0,-1,2 LR ______+2,1,0,-1,2 ROM PAIN SCALE: -2 = centralization; -1 = decreased pain; 0 = no change in pain; +1 = increased pain; +2 = peripheralization

COMMENTS______GO ONTO PAGE 2    

22

NAME______DATE______DOI______

Supine TESTS L R L R L R L R 15.* (2 methods) Fl______RLF______Fl______RLF______Fl______RLF______Fl______RLF______CERVICAL STRENGTH –mmHg (dynamometer) Ext_____ LLF______Ext_____ LLF______Ext_____ LLF______Ext_____ LLF______CHIN FLEXION TEST (timed) C-Flexion Test: C-Flexion Test: C-Flexion Test: C-Flexion Test: Time to the point of Shakes / Drops head ______/______Sec. ______/______Sec. ______/______Sec. ______/______Sec. 16. Repetitive Sit-up Test Endurance Endurance Endurance Endurance  Sit-up, knees 90, feet anchored, 1

rep/2-3 sec, touch thenar to patella, reps______/ 50 reps______/ 50 reps______/ 50 reps______/ 50 curl back down; max.50 reps 17. Hip Flexion Test /

Modified Thomas  Measure: Passive Hip extension a. _____ a. _____ a. _____ a. _____ a. _____ a. _____ a. _____ a. _____ (psoas tension) 18. Hip Flexion/Supine SLR a. + / - a. + / - a. + / - a. + / - a. + / - a. + / - a. + / - a. + / - a. Waddell #3: supine + vs. sit- SLR b. Measure angle: at point of knee b.___ b.___ b.___ b.___ b.___ b.___ b.___ b.___ flexion 19. Double Leg Lowering (maintain lordosis < 65 degrees) ______degrees ______degrees ______degrees ______degrees

Prone TESTS L R L R L R L R 20. Static Back Endurance Static Static Static Static  Static Back Endurance: Pt holds trunk Time______/240 Time______/240 Time______/240 Time______/240 horizontal up to max. of 240 sec. sec. sec. sec. sec. 21. Knee Flexion Test /

Modified Nachlas Test ______ ______ ______ ______ ______ ______ ______ ______ 22. Hip ROM IR ____ IR ____ IR ____ IR ____ IR ____ IR ____ IR ____ IR ____  Internal Rotation  External Rotation ER ___ ER ___ ER ___ ER ___ ER ___ ER ___ ER ___ ER ___

TESTS L R L R L R L R 23. Grip Dynamometry 1._____ 1._____ 1._____ 1._____ 1._____ 1._____ 1._____ 1._____ Dominant: Left / Right (circle)  Use Jamar 2._____ 2._____ 2._____ 2._____ 2._____ 2._____ 2._____ 2._____

 Use Position 1 or 2 3._____ 3._____ 3._____ 3._____ 3._____ 3._____ 3._____ 3._____  Three trials (average) ave_____ ave_____ ave_____ ave_____ ave_____ ave_____ ave_____ ave_____ 24. Repetitive Arch Up Test  Repetitive arch up: Waist at table's edge fixed at ankle flexed 45 raises up to horizontal; 1 rep/2-3 seconds; max. 50reps Reps______/50 Reps______/50 Reps______/50 Reps______/50 25. Post-Test VAS _____/10 _____/10 _____/10 _____/10

SIGNED______DATE______TIME OUT______SIGNED______DATE______TIME OUT______SIGNED______DATE______TIME OUT______SIGNED______DATE______TIME OUT______23 QUANTITATIVE FUNCTIONAL CAPACITY RESULTS NAME: ______Occupation: WC / BC* DATE:______BD:______AGE:______Dx:______Test #: 1, 2, 3, 4 Symptom Duration:______Prior Episodes: YES / NO

TEST NAME NORMAL PATIENT RESULT PERCENT OF NORMAL 1. Pre-test VAS 0/10 /10 2. 3-minute Step Test (pulse) ______/______yo F M _____ Pre- ____Post- % 3. ROM / Lumbar Spine Flexion 65° ° % Extension 30° ° % Rt. Lateral Flexion 25° ° % Lt. Lateral Flexion 25° ° % 4. Waddell #1: Pain Negative Positive / Negative NA 5. Waddell #2: Simulation Negative Positive / Negative NA 6. Horizontal Side Bridge ______(max. 240 sec.) ______sec. % 7. Gastrocnemius /Ankle DF 23° Lt.: Rt.: % % 8. Soleus / Ankle DF 25° Lt.: Rt.: % % 9a & b. One leg standing test EO____sec. EC_____ L___/___ R___/___ L___/___ R___/___ 10. Waddell #5: Exaggeration Negative Positive / Negative NA 11. Repetitive Squat * / (max 50) / ( ) % 12. Sitting SLR/ Distraction w/ #17a LBP: YES / NO LBP: YES / NO NA 13. Waddell #4: Regional Neuro Negative Positive / Negative NA 14. ROM / Cervical Flexion 50° ° % Extension 63° ° % Rt. Lateral Flexion 45° ° % Lt. Lateral Flexion 45° ° % Rt Rotation 85° ° % Lt Rotation 85° ° % 15. Cervical spine strength NOT ESTABLISHED Fl______RLF______C-Flexion Test: 2 methods: 1) Sphyg; 2) C-Flex T. Ext______LLF______Shake/drop____/____Sec. 16. Repetitive Sit-Up * ______(max. 50) ______/ ( ) % 17. Hip flexion/Modified Thomas Iliopsoas 84° Lt.: Rt.: % % 18a. Waddell #3: Distraction/SLR Negative Positive / Negative NA 18b. Straight Leg Raise * 80° Lt.: Rt.: % % 19. Double leg lowering <65 degrees w/ pelvic tilt ______degrees ______% 20. Static Back Endurance * ______(max. 240 sec.) ______seconds % 21. Knee Flexion 147 +/- 1.6 Lt.: Rt.: % % 22. Hip Rotation ROM Internal Rotation ROM 41-45 (43) Lt.: Rt.: % % External Rotation ROM 41-43 (42) Lt.: Rt.: % % 23. Grip Strength * Lt.: Kg Rt.: Kg Lt.: Kg Rt.: Kg % % 24. Repetitive Arch-Up * ______(max. 50) ______/ ( ) % 25. Post-test VAS 0/10 /10 AGE years EYES OPEN (seconds) EYES CLOSED (seconds) 20-59 29-30 21-28.8 (25 Sec. ave.) 60-69 22.5 ave 10 70-79 14.2 4.3 * Normative data is determined by age, sex and occupation (Blue vs. white collar: BC / WC) ** A positive test #13 (Supine SLR) and a negative sitting / distracted SLR (test #8)= +Waddell sign for Distraction

SIGNED ______DATE______24

NAME: Ken Esthetic Occupation: WC DATE: 10-30-98 BD: 1-19-58 AGE: 40 Dx: LBP w/o leg pain Test #: 1, 2, 3, 4 Symptom Duration: 3 weeks Prior Episodes: YES / NO TEST NAME NORMAL PATIENT RESULT PERCENT OF NORMAL 1. Pre-test VAS 0/10 2 /10 80% 2. 3-minute Step Test (pulse) ___40_yo F M __81_ Pre- _92_Post- 78% 3. ROM / Lumbar Spine Flexion 65° 56 ° 86% Extension 30° 25__ ° 83% Rt. Lateral Flexion 25° 27 ° 108% Lt. Lateral Flexion 25° 28 ° 112 % 4. Waddell #1: Pain Negative Positive / Negative NA 5. Waddell #2: Simulation Negative Positive / Negative NA 6. Horizontal Side Bridge 96M, 75W(max. Lt__89_/Rt__91_ sec. 93% 95% 240sec.) 7. Gastrocnemius /Ankle DF 23° Lt.: 21 Rt.: 24 91% 104% 8. Soleus / Ankle DF 25° Lt.: 23 Rt.: 26 92% 104% 9a & b. One leg standing test EO_30_sec. EC_30__ L_30/17_ R_28/13_ L 100% / 57% R 93% / 43% 10. Waddell #5: Exaggeration Negative Positive / Negative NA 11. Repetitive Squat * 45 / (max 50) 42 / ( 45 ) 93% 12. Sitting SLR/ Distraction w/ #18a LBP: YES / NO LBP: YES / NO NA 13. Waddell #4: Regional Neuro Negative Positive / Negative NA 14. ROM / Cervical Flexion 50° 56 ° 112% Extension 63° 58_ ° 92% Rt. Lateral Flexion 45° 44_ ° 98% Lt. Lateral Flexion 45° 42 ° 93% Rt Rotation 85° 78 ° 92% Lt Rotation 85° 82 ° 96% 15. Cervical spine strength NOT ESTABLISHED Fl___8___ C-Flexion Test: 2 methods: 1) Sphyg; 2) C-Flex T. RLF___6___ Ext__16___ Shake/drop15/35 Sec LLF__6____ 16. Repetitive Sit-Up * ___34___ (max. 50) __46___/ ( 34 ) 125 % 17. Hip flexion/Modified Thomas Iliopsoas 84° Lt.: 76 Rt.: 64 90 % 76 % 18a. Waddell #3: Distraction/SLR Negative Positive / Negative NA 18b. Straight Leg Raise * 80° Lt.: 76 Rt.: 70 100 % 100 % 19. Double leg lowering <65 degrees w/ pelvic ____76__ degrees 86% tilt 20. Static Back Endurance * __129__ (max. 240 sec.) ___96__ seconds 74% 21. Knee Flexion 147 +/- 1.6 Lt.: 126 Rt.: 135 86 % 92 % 22. Hip Rotation ROM Internal Rotation ROM 41-45 (43) Lt.: 40 Rt.: 43 93 % 100 % External Rotation ROM 41-43 (42) Lt.: 41 Rt.: 43 98 % 102 % 23. Grip Strength (Kg) * Lt.: 47 Rt.: 49 Lt.: 52 Rt.: 58 111 % 118 % 24. Repetitive Arch-Up * ____36__ (max. 50) ___45__/ ( 36 ) 125 % 25. Post-test VAS 0/10 1 /10 90% AGE years EYES OPEN (seconds) EYES CLOSED (seconds) 20-59 29-30 21-28.8 (25 Sec. ave.) 60-69 22.5 ave 10 70-79 14.2 4.3 * Normative data is determined by age, sex and occupation (Blue vs. white collar: BC / WC) ** A positive test #18a (Supine SLR) and a negative sitting / distracted SLR (test #12)= +Waddell sign for Distraction

25 PLEASE REFER TO THE FOLLOWING CHARTS FOR THE NORMATIVE DATA OF THE TESTS THAT VARY DUE TO AGE &/OR GENDER TESTS (TESTS 2, 9, 11, 16, 20, 23, & 24). THE NORMS FOR THE OTHER TESTS (NOT BROKEN DOWN BY AGE/GENDER/WORK CLASSIFICATION) ARE LISTED IN THE LEFT OF THE 3 COLUMNS TO RIGHT OF THE TEST NAME IN THE QFCE SUMMARY CHART (IN THE “NORMAL” COLUMN).

STRENGTH AND ENDURANCE NORMATIVE DATA

1. Repetitive Squatting Test AGE MALES (n=242) FEMALES (n=233) Blue Collar White Collar All Blue Collar White Collar All x SD x SD x SD x SD x SD x SD

35-39 39 13 46 8 42 12 24 11 27 12 26 12 40-44 34 14 45 9 38 13 22 13 18 8 20 12 45-49 30 12 40 11 33 13 19 12 26 13 22 13 50-54 28 14 41 11 33 14 13 10 18 14 14 11 35-54 33 14 43 10 37 13 20 12 23 12 21 12

2. Repetitive Sit-up Test AGE MALES (n=242) FEMALES (n=233) Blue Collar White Collar All Blue Collar White Collar All x SD x SD x SD x SD x SD x SD

35-39 29 13 35 13 32 13 24 12 30 16 27 14 40-44 22 11 34 12 27 13 18 12 19 13 19 12 45-49 19 11 33 15 24 14 17 14 22 15 19 14 50-54 17 13 36 16 23 16 9 10 20 13 11 11 35-54 23 13 35 13 27 14 17 13 24 15 19 14

3. Repetitive Arch-up Test

AGE MALES (n=242) FEMALES (n=233) Blue Collar White Collar All Blue Collar White Collar All x SD x SD x SD x SD x SD x SD

35-39 26 11 34 14 29 13 28 13 27 11 27 12 40-44 23 12 36 14 28 14 25 14 20 11 23 13 45-49 24 13 34 16 28 15 25 15 31 16 27 15 50-54 21 11 35 17 26 15 18 14 26 14 19 14 35-54 24 12 35 15 28 14 24 14 26 13 24 14

4. Static back endurance test (sec) AGE MALES (n=242) FEMALES (n=233) Blue Collar White Collar All Blue Collar White Collar All x SD x SD x SD x SD x SD x SD

35-39 87 38 113 47 97 43 91 61 95 48 93 55 40-44 83 51 129 57 101 57 89 57 67 51 80 55 45-49 81 45 131 64 99 58 90 55 122 73 102 64 50-54 73 47 121 56 89 55 62 55 99 78 69 60 35-54 82 45 123 55 97 53 82 58 94 62 87 59

X = AVERAGE; SD = Standard deviation; Note: The last row represents the average of all the ages (35-54)

26 REFERENCES 1. Alaranta H, Hurri H, Heliovaara M, et al. Non-dynamometric trunk performance tests: Reliability and normative data. Scand J Rehab Med 1994; 26:211-215. 2. The Clinical Application of Outcomes Assessment. Ed.: Yeomans, SG. (Stamford, CT:) Appleton & Lange. 2000; chapters 12 & 16. ISBN #: 0-8385-1528-2. 3. Yeomans S, Liebenson C. Quantitative functional Capacity Evaluation: The Missing Link to Outcomes Assessment. Top Clin Chiro 1996; 3(1): 32-43.

The Horizontal Side-bridge

McGill SM, Childs A, Leibenson C. endurance times for stabilization exercises: clinical targets for testing and training from a normal database. Arch Phys Med Rehabil 1999; 80:941-4.

Abstract:

Objective: to establish isometric endurance holding times, as well as ratios between torso extensors, flexors, and lateral flexors (stabilizers), for clinical assessment and rehabilitation targets. Design: simple measurement of endurance times in four tests performed in random order by a healthy cohort. To measure reliability, a subsample also perform the tests again 8 weeks later. Setting: university laboratory. Participants: 75 young healthy subjects (31 men, 44 women). Results: women had longer endurance times than men for torso extension, but not for torso flexion or for the "side bridge" exercise, which challenges the lateral flexors (stabilizers). Men could sustain the "side bridge" for 65 percent of the extensor time and 99 percent of the flexion time, whereas women could sustain the "side bridge" for only 39 percent of the extensor time and 79 percent of the flexion time. The tests proved to be reliable, with reliability coefficients of > 0.97 for the repeated tests on five consecutive days and again 8 weeks later. Conclusion: healthy young men and women possess different endurance profiles for the spine stabilizing musculature. Given the growing support for quantification of endurance, these data of endurance times and thigh ratios between extensor, flexors, and lateral flexors groups in healthy normal subjects are useful for patient evaluation and providing clinical training targets.

The Horizontal Side Bridge Men Women All Task Mean SD Ratio Mean SD Ratio Mean SD Ratio Extensor 146 51 1.0 189 60 1.0 177 60 1.0 Flexor 144 76 0.99 149 99 0.79 147 90 0.86 Side Bridge, Rt 94 34 0.64 72 31 0.38 81 34 0.47 Side Bridge, Lt 97 35 0.66 77 35 0.40 85 36 0.5 Average: 95 75

Patient position: side lateral, top leg in front of lower leg resting on lower hip/thigh and elbow. The upper arm is placed against chest with the hand touching the anterior lower shoulder. The pelvis is raised off the table and held in a line with a long axis of the body supporting the weight between the feet and elbow. The down side QL is being tested.

27 GRIP AND PINCH STRENGTH NORMATIVE DATA TABLE 1 Grip Strength MALES FEMALES (Kg) OCCUPATION Major hand Minor hand Major hand Minor hand Skilled 47.0 45.4 26.8 24.4 Sedentary 47.2 44.1 23.1 21.1 Manual 48.5 44.6 24.2 22.0 Average 47.6 45.0 24.6 22.4 Table 1. The normative data for dominant (“major hand”) and non-dominant (“minor hand”) grip strength (in kilograms) broken down by occupation (left hand column) and gender.

TABLE 2 Grip Strength MALES FEMALES (Kg) AGE GROUP Major hand Minor hand Major hand Minor hand <20 45.2 42.6 23.8 22.8 20-29 48.5 46.2 24.6 22.7 30-39 49.2 44.5 30.8 28.0 40-49 49.0 47.3 23.4 21.5 50-59 45.9 43.5 22.3 18.2 Table 2. The normative data for dominant (“major hand”) and non-dominant (“minor hand”) grip strength (in kilograms) broken down by age (left hand column) and gender.

TABLE 3 PINCH Strength MALES FEMALES (Kg) OCCUPATION Major hand Minor hand Major hand Minor hand Skilled 6.6 6.4 4.4 4.3 Sedentary 6.3 6.1 4.1 3.9 Manual 8.5 7.7 6.0 5.5 Average 7.5 7.1 4.9 4.7 Table 3. The normative data for dominant (“major hand”) and non-dominant (“minor hand”) pinch strength (in kilograms) broken down by occupation (left hand column) and gender.

Reprinted with permission from Swanson AB, Matev IB, de Groot Swanson G. The strength of the hand. AMA Guides, 1993, 4th edition, pg. 64, Table 31; p. 65, Table 32; pg. 65, Table 33.

3-MINUTE STEP TEST

 Check the patient’s pre-test pulse (30 x 2 standing): R/O Tachycardia (>100b/m)  Patient steps up and down off of a 12” bench at the rate of 24 steps per minute for 3-minutes (Metronome 96 b/m) “up, up, down, down”  Immediately (within 5 seconds), sit patient down and recheck the patient’s pulse for a full minute and compare to the normative data

28 3 Minute Step Test Normative Data for Men % Men Men Men Men Men Men Rating ranking Age 18-25 Age 26-35 Age 36-45 Age 46-55 Age 56-65 Age >65 Excellent 100 70 bpm 73 72 78 72 72 95 72 76 74 81 74 74 90 78 79 81 84 82 86 Good 85 82 83 86 89 89 89 80 85 85 90 93 93 92 75 88 88 94 96 97 95 Above Avg 70 91 91 98 99 98 97 65 94 94 100 101 100 100 60 97 97 102 103 101 102 Average 55 101 101 105 109 105 104 50 102 103 108 113 109 109 45 104 106 111 115 111 113 Below Avg 40 107 109 113 118 113 114 35 110 113 116 120 116 116 30 114 116 118 121 118 119 Poor 25 118 119 120 124 122 122 20 121 122 124 126 125 126 15 126 126 128 130 128 128 Very Poor 10 131 130 132 135 131 133 5 137 140 142 145 136 140 0 164 164 168 158 150 152 Aerobic capacity values and rankings for 3-minute step test for men. (Adapted from Y’s Way to physical Fitness with permission of the YMCA of the USA, 101 N. Wacker Drive, Chicago, Il 60606.)

3 Minute Step Test Normative Data for Women Rating % Women Women Women Women Women Women ranking Age 18-25 Age 26-35 Age 36-45 Age 46-55 Age 56-65 Age >65 Excellent 100 72 bpm 72 74 76 74 73 95 79 80 80 88 83 83 90 83 86 87 93 92 86 Good 85 88 91 93 96 97 93 80 93 93 97 100 99 97 75 97 97 101 102 103 100 Above Avg 70 100 103 104 106 106 104 65 103 106 106 111 109 108 60 106 110 109 113 111 114 Average 55 110 112 111 117 113 117 50 112 116 114 118 116 120 45 116 118 117 120 117 121 Below Avg 40 118 121 120 121 119 123 35 122 124 122 124 123 126 30 124 127 127 126 127 127 Poor 25 128 129 130 127 129 129 20 133 131 135 131 132 132 15 137 135 138 133 136 134 Very Poor 10 142 141 143 138 142 135 5 149 148 146 147 148 149 0 155 154 152 152 151 151 Aerobic capacity values and rankings for 3-minute step test for women. ______

29

NAME: ______DATE: ______

ASSESSMENT

 Dx classif.: Mechanical, Nerve root, Red Flags; Other ______

Capturing Biopsychosocial Information (see Severity Index for a quantitative method or risk assessment)

Yellow Flags A past history of prior episodes Depression Duration of symptoms before the 1st visit (>1wk) Severe pain intensity (>6/10) Sciatica Multiples sites of pain Duration of symptoms (>1 mo.) Catastrophizing Tolerance for light work Anxiety Job dissatisfaction Physical activity makes pain worse Sleep is affected by pain Activity intolerance Belief that shouldn’t work with current pain

Other Risk Factors of chronicity Abnormal illness behavior Weak back extensor musculature Heavy Job Classification Job dissatisfaction Smokes 1 pack or greater / day Pre-existing structural pathol./ skeletal anomaly Poor self-rated health

Goal Setting:

Short-term Goals: Long-term Goals: 1. Decrease pain ______% in ______days. 1. Functional restoration. 2. Increase ROM ______% in ______days. 2. Initiate Active / Home care. 3. Decrease spasm in ______days. 3. Rehabilitation / Strengthening. 4. Return to work in ______days. 4. Education / "Back school". 5.______5. ______

DRAGON MACRO FOR GOALS:

Short-term goals: Decrease pain, increase range of motion, and ambulatory function 50% over the next 20-30 days. Please refer to the ______{insert name of OAT form} outcome assessment tools for a patient specific set of goals. Long-term goals: Functional restoration, initiate a home/active care, a guided rehabilitation /strengthening program.

30 PLAN NAME: ______DATE: ______

Therapy Frequency Remarks Chiro. Manipulative Rx ______x/week, Ice/heat 15 minute rotations: on / off / on x 3 = 1.25 hr / x Interferential current Acute: 80-100 cps / 10-15 min.; Subacute: 0-100 cps / 15 min. Chronic: 0-10 cps / 15 min. Traction Cerv. long axis Office: _____ Pounds / _____ minutes Lumb.long axis Intersegmental Home: _____ Pounds / _____ minutes Exercises Acute: Isometric w/in pain boundaries Flexion Subacute: Isotonic, passive ROM to boundary, Extension Initiate proprioception retraining QFCE ____(date) Chronic: Evaluate functional status (QFCE), Work hardening Initiate isokinetic, progressive resistance Other ______MRI / CT / Bone scan X-R Lumbar, Thoracic, Cervical, Extrem__ Davis, 5-Series, 3-series, 2-series Lab Blood Test______; Urine Test: UA, Culture, _____ Restrict activities: Work: Regular duty Work Light duty ADL's Total temporary disability: ______Re-eval for RTW ______days, weeks Progress re-eval 1, 2, 3, 4, 6, weeks Referral to: Specialty service Disability / Impairment rating / WCE PROCEDURES PASSIVE CARE: CMT ______PT ______MFR______PNF/NMR (MRT's) ______Manual Traction ______Hot / Cold ______Vibration______Other______ACTIVE CARE:  Kinetic Activity Home exercise Williams ______McKenzie______PNF ______Tubing/Band ______Other______

31 NAME: ______DATE: ______

Pelvic stabilization Gym ball ______Floor ______Other ______Proprioceptive retraining Gym ball ______Balance shoes______Rocker board______Wobble board______Other______

FUNCTIONAL CAPACITY EVALUATION Spinal Function Sort QFCE Static Position Tolerance Tests Lift / Carry tests (i.e., EPIC, PILE)

REFERRAL / CO-TREATMENT / MONITOR / DISCHARGE

______

32

NAME______PHYSICAL THERAPY DATE THERAPY AREA /SETTING / DATE THERAPY AREA /SETTING / (CIRCLE) notes (CIRCLE) notes HOT HOT IFC IFCCOLD COLD US USLA-TX LA-TX GALV GALVIS-TX IS-TX MSTIM MSTIM HOT HOT IFC IFCCOLD COLD US USLA-TX LA-TX GALV GALVIS-TX IS-TX MSTIM MSTIM HOT HOT IFC IFCCOLD COLD US USLA-TX LA-TX GALV GALVIS-TX IS-TX MSTIM MSTIM HOT HOT IFC IFCCOLD COLD US USLA-TX LA-TX GALV GALVIS-TX IS-TX MSTIM MSTIM HOT HOT IFC IFCCOLD COLD US USLA-TX LA-TX GALV GALVIS-TX IS-TX MSTIM MSTIM HOT HOT IFC IFCCOLD COLD US USLA-TX LA-TX GALV GALVIS-TX IS-TX MSTIM MSTIM HOT HOT IFC IFCCOLD COLD US USLA-TX LA-TX GALV GALVIS-TX IS-TX MSTIM MSTIM HOT HOT IFC IFCCOLD COLD US USLA-TX LA-TX GALV GALVIS-TX IS-TX MSTIM MSTIM HOT HOT IFC IFCCOLD COLD US USLA-TX LA-TX GALV GALVIS-TX IS-TX MSTIM MSTIM HOT HOT IFC IFCCOLD COLD US USLA-TX LA-TX GALV GALVIS-TX IS-TX MSTIM MSTIM HOT HOT IFC IFCCOLD COLD US USLA-TX LA-TX GALV GALVIS-TX IS-TX MSTIM MSTIM HOT HOT IFC IFCCOLD COLD US USLA-TX LA-TX GALV GALVIS-TX IS-TX MSTIM MSTIM HOT HOT IFC IFCCOLD COLD US USLA-TX LA-TX GALV GALVIS-TX IS-TX MSTIM MSTIM HOT HOT IFC IFCCOLD COLD US USLA-TX LA-TX GALV GALVIS-TX IS-TX MSTIM MSTIM HOT HOT IFC IFCCOLD COLD US USLA-TX LA-TX GALV GALVIS-TX IS-TX MSTIM MSTIM

33 ______

Patient Date Account #

$______$______$______Previous Balance Total Charges Payment Injury Date

Yeomans-Edinger Chiropractic Center, SC Next Visit: ______ Work Comp  U-Care 404 Eureka Street  Auto Accident  WEA/WPCN Ripon, WI 54971-0263 ______x / week x _____ weeks  United Health  Medical Assistance 920-748-3644(Tele); 920-748-3642 (Fax)  Network Health  Medicare ______ Other: ______

NEW PATIENT -25 LABORATORY SERVICE

99201 208 193 Focused History/Exam ______49 Chem. Screen 26 ______99202 209 194 Focused History/Exam ______50 CBC With Differential ______99203 210 195 Detailed History/Exam ______51 Arthritic Profile ______99204 211 196 Comp. History/Exam ______52 Urinalysis ______99205 212 197 Comp. History/Exam ______53 Glucose ______56 Sedimentation Rate ______57 TMA ______ESTABLISHED PATIENT -25 58 Thyroxin (T-4) ______61 HDL ______99211 213 198 O.V./Eval . ______63 Beta Strep ______99212 214 199 Focused History/Exam ______118 Lymes ______99213 215 200 Focused History/Exam ______127 Lab Handling ______99214 216 201 Detailed History/Exam ______182 Executive Panel ______99215 217 202 Comp. History/Exam ______

TREATMENT MC RADIOLOGY

98940 218 203 CMT Spinal 1-2 regions ______72040 178 Cervical Spine AP/LAT ______98941 219 204 CMT Spinal 3-4 regions ______72040 18 Cervical Spine AP/LAT/OM ______98942 220 205 CMT Spinal 5 regions ______72050 19 Cervical Spine 5 Views ______98943 207 CMT extremity adjustl 1+ _____ Flex/ext 98943-25 206 CMT extremity adjustl 1+ _____ Obliques W9010 116 Spinal Adjustment/ 72052 20 Davis Series Complete ______Manipulation E.D.S. _____ 72050 21 Stress C-Spine 3 Views ______97265 185 Joint Mobilization _____ 72070 22 Thoracic Spine 2 Views ______Wellness Care _____ 72100 23 Lumbosacral 2 Views ______Same Day Pay _____ 72110 24 Lumbosacral Com./6 Views ______72170 25 Pelvis A/P ______73564 27 Knee 4 Views ______PHYSIOTHERAPY TREATMENT 73030 28 Shoulder 2 Views ______73630 29 Foot 3 Views ______97010 100 Hot/Cold Pack ______73610 30 Ankle 3 Views ______97012 101 Interseg. Traction ______73520 36 Hip 3 Views ______97014 102 Electrical Stimulation ______76140 47 Exam of Films/Report ______A4556 190 Electrodes ______72020 40 X-Ray, Single View ______97012 120 Traction ______97122 189 Manual Traction ______97112 154 PMT, Neuromuscular ______97530 175 Therapeutic activities, ______SUPPORTIVE THERAPY (+TAX) direct (one on one) 82 Cervical Pillow ______patient contact by the 87 C-Traction ______provider (use of dynamic 88 Ice Pack ______activities to improve 91 Heel Lift ______functional performance), 93 Prescription Foot Orthotics ______each 15 minutes. 98 Nutritional Supplementation ______97110 180 wpcn neuromuscular ______183 Gym Ball ______97750 186 FCE, Rehab screen ______184 Balance Board ______($20.50/15 min. testing) Theratube ______97140-59 187 Myofascial Release ______188 Intracell ______(spr/str, vib, TPT) 191 1/2 Foam Roll ______

ORTHOPEDIC APPLIANCES ______

34

CERVICAL LUMBAR, CONTINUED WRIST 1 Sprain Cervical 30 Inter. Disc Lumbar 6 Carpal Tunnel 29 Inter. Disc Cervical 31 Spondylolisthesis 90 Sprain/Strain-Wrist 176 Headache 61 Spondylolysis 88 Sprain/Strain-Finger 8 Myositis, Myalgia, Myofascitis 9 Facet Syndrome 83 Sprain/Strain-Elbow/Forearm 32 Cervicalgia 10 Sciatic Neuralgia 281 de Quarvain's Disease 33 Migraine 219 Spinal Stenosis 34 Torticollis 44 Scoliosis (acq.) KNEE 37 TMJ Syndrome 94 Bursitis, Hip 112 Sprain/Knee 241 Osteoarthritis 224 Meral. Paresthetica 115 Sprain/Cruciate 4 Brachial Radiculitis 99 Sprain/Strain hip or thigh 113 Sprain/Medial Collateral 104 Synovitis/Pelvis-Hip 107 Bursitis/Knee THORACIC 239 Osteoarthritis (721.3) 118 Meniscus Tear-Medial 2 Sprain Thoracic 220 Short Leg (Acquired) 11 Thoracic Outlet Syndrome ANKLE 73 Costochondritis SHOULDER 126 Sprain/Strain-Ankle 36 Intercostal Neuralgia 5 Rotator Cuff Syndrome 108 Chondromalacia Patella 38 Rib Sprain/Strain 218 Bursitis (Shoulder) 180 Ulnar Nerve Lesion 232 Thor. Spondylosis w/o Myel. 79 Adhesive Capsulitis 240 Osteoarthritis (721.2) 71 Acromioclavicular, Sprain MISCELLANEOUS 290 Displacement of Thoracic IVD 123 Pes Planus without myelopathy ELBOW 142 Muscle Spasm 86 Tenosynovitis, Elbow 262 Plantar Fascitis LUMBAR 81 Medial Epicondylitis, Elbow 206 Rheumatoid Arthritis (714.0) 3 Sprain Lumbar 82 Lateral Epicondylitis, Elbow 211 257 Sprain/Strain SI 279 Contusion of Elbow 139 258 Sprain/Strain Lumbosacral 278 Contusion of Forearm 259 Sprain/Strain Iliofemoral MEDICARE ACUTE CONDITIONS 723.3 739.1 Cervicobrachial syndrome 307.81 739.0 or 739.1 Tension headache 724.2 739.3 Lumbago 346.0 739.0 or 739.1 Classical migraine COMPLICATING CONDITIONS 346.1 739.0 or 739.1 Common Migraine 355.2 739.4 Outer lesions/femoral nerve 346.9 739.0 or 739.1 Migraine unspecified plexus 355.8 739.3 or 739.4 Mononeuritis of lower limb, lesions unspecified 722.10 739.3 or 739.4 Sciatica 386.0 739.0 Menieres syndrome 723.1 739.1 Cervicalgia 721.5 739.0 - 739.4 Kissing spine 723.4 739.1 Brachial neuritis or radiculitis 721.6 739.0 - 739.4 Ankylosing vertebral hyperostosis 723.5 739.1 Torticollis, unspecified 721.7 739.0 - 739.4 Traumatic spondylopathy 724.1 739.2 Pain in thoracic spine 722.31 739.2 Schmorl's Nodes thoracic reg. 724.4 739.2 or 739.3 Thoracic or lumbosacral neuritis or 722.32 739.4 Schmorl's Nodes lumbar region radiculitis 722.81 739.1 Post Laminectomy/cervical 724.79 739.4 Coccygodynia/disorder/coccyx 722.82 739.2 Post Laminectomy/thoracic 728.85 739.0 - 739.4 Muscle spasm 722.83 739.3 Post Laminectomy/lumbar reg. 784.0 739.0 or 739.1 Headache 723.0 739.0 or 739.1 Spinal stenosis/cervical reg. 846.0 739.3 or 739.4 Sprains/ strains of lumbosacral) 724.01 739.2 Spinal stenosis/thoracic reg. 846.1 739.4 Sprains of sacroiliac Ligament 724.02 739.3 Spinal stenosis/lumbar region 846.2 739.4 Sprains of sacrospinatus ligament 724.6 739.4 Disorders of sacrum 846.3 739.4 Sprains of sacrotuberous ligament 733.01 739.0 - 739.4 Senile osteoporosis 847.0 739.0 or 739.1 Sprains / strains of neck 733.02 739.0 - 739.4 Idiopathic osteoporosis 847.1 739.2 Sprains / strains of thoracic 733.03 739.0 - 739.4 Disease osteoporosis 847.2 739.3 Sprains / strains of lumbar 737.10 739.0 - 739.4 Kyphosis (acquired)(postural) 847.3 739.4 Sprains / strains of sacrum 737.11 739.0 - 739.4 Kyphosis due to radiation 847.4 739.4 Sprains / strains of coccyx 737.12 739.0 - 739.4 Kyphosis, post-laminectomy CHRONIC CONDITIONS 737.20 739.0 - 739.4 Lordosis (acquired)(postural) 353.2 739.1 Cervical root lesions 737.21 739.0 - 739.4 Lordosis, post-laminectomy 353.3 739.2 Thoracic root lesions 737.22 739.0 - 739.4 Other post-surgical lordosis 353.4 739.2 Lumbosacral root lesions 737.33 739.0 - 739.4 Scoliosis due to radiation 721.1 739.1 Cervical spondylosis w/myel. 737.34 739.2 Thoracogenic scoliosis 721.41 739.2 Thoracic spondylosis w/myel. 738.2 739.0 or 739.1 Acquired deformity of neck 721.42 739.3 Lumbar spondylosis w/myel. 738.4 739.0 - 739.4 Acquired spondylolisthesis 722.0 739.1 Displacement of cerv. IVD w/o 754.2 739.0 - 739.4 Congenital scoliosis myel 756.11 739.3 or 739.4 Spondylosis, lumbosacral reg. 722.10 739.3 Lumbar IVD w/o myel. 756.12 739.0 - 739.4 Spondylolisthesis 722.11 739.2 Thoracic IVD w/o myel. 756.13 739.0 - 739.4 Absence of vertebra, conge. 722.4 739.1 Degeneration of cervical disc 756.14 739.0 - 739.4 Hemivertebra 722.51 739.2 Degeneration of thoracolumbar 756.15 739.0 - 739.4 Fusion of spine, congenital IVD 756.16 739.0 - 739.4 Klippel-Feil syndrome 722.52 739.3 Degeneration of lumbosacral IVD 737.30 739.1, 2, 3 Scoliosis (kyphoscol.), idiopathic 723.2 739.1 Cervicocranial syndrome 35 FUNCTIONAL CAPACITY EVALUATION - DISCUSSION (Lift/Carry limits, Spinal function sort, SPTT)

Job Demands Questionnaire

Name______Date ______Age ______Sex: M / F

Employer ______Job Title______No. of Years Employed______

1. How many hours per week do you usually work on this job?_____

2. Work postures: For this job, fill in the hours per day that you usually work in the following postures.

Max. at 1 Time Total Hours -Sitting down (office, car, truck, etc.) ______-Standing (at a counter, at a machine, etc.) ______-Walking while carrying less than 20 pounds ______-Walking while carrying more than 20 pounds ______

3. How often do you have to kneel or crawl in your work? ( ) ( ) ( ) ( ) ( ) NOT AT ALL RARELY OCCASIONALLY FREQUENTLY CONSTANTLY (never) (less than 1/10 of (less than 1/3 of the (1/3 to 2/3 of the (more than 2/3 of the time) time) time) the time)

4. How often do you have to lie down (for example, as an auto mechanic) in your work? ( ) ( ) ( ) ( ) ( ) NOT AT ALL RARELY OCCASIONALLY FREQUENTLY CONSTANTLY (never) (less than 1/10 of (less than 1/3 of the (1/3 to 2/3 of the (more than 2/3 of the time) time) time) the time)

5. How often do you have to squat or remain bent or twisted at the hips in your work? ( ) ( ) ( ) ( ) ( ) NOT AT ALL RARELY OCCASIONALLY FREQUENTLY CONSTANTLY (never) (less than 1/10 of (less than 1/3 of the (1/3 to 2/3 of the (more than 2/3 of the time) time) time) the time)

6. How often do you do work which caused vibrations to your whole body? ( ) ( ) ( ) ( ) ( ) NOT AT ALL RARELY OCCASIONALLY FREQUENTLY CONSTANTLY (never) (less than 1/10 of (less than 1/3 of the (1/3 to 2/3 of the (more than 2/3 of the time) time) time) the time)

7. Do you have to operate a foot pedal? ( ) ( ) ( ) ( ) ( ) NOT AT ALL RARELY OCCASIONALLY FREQUENTLY CONSTANTLY (never) (less than 1/10 of (less than 1/3 of the (1/3 to 2/3 of the (more than 2/3 of the time) time) time) the time)

36

(Pg. 2) NAME: ______DATE: ______

8. On this job, how often do you lift:

not at all rarely occasionally frequently constantly (never) (less than (less than (1/3 to 2/3 (more than 1/10 of the 1/3 of the of the time) 2/3 of the time) time) time) 10 to 20 lbs. ( ) ( ) ( ) ( ) ( ) 20 to 50 lbs. ( ) ( ) ( ) ( ) ( ) 50 to 100 lbs. ( ) ( ) ( ) ( ) ( ) More than 100 lbs. ( ) ( ) ( ) ( ) ( )

9. On this job, how often do you carry:

not at all rarely occasionally frequently constantly (never) (less than (less than (1/3 to 2/3 (more than 1/10 of the 1/3 of the of the time) 2/3 of the time) time) time) 10 to 20 lbs. ( ) ( ) ( ) ( ) ( ) 20 to 50 lbs. ( ) ( ) ( ) ( ) ( ) 50 to 100 lbs. ( ) ( ) ( ) ( ) ( ) More than 100 lbs. ( ) ( ) ( ) ( ) ( )

10. How often do you jump from one level to another? (For example, jumping down from a truck cab or from a loading dock.)

( ) ( ) ( ) ( ) ( ) NOT AT ALL RARELY OCCASIONALLY FREQUENTLY CONSTANTLY (never) (less than 1/10 of (less than 1/3 of the (1/3 to 2/3 of the (more than 2/3 of the time) time) time) the time)

11. About how often per day do you climb a flight of steps on this job?

( ) ( ) ( ) ( ) ( ) NOT AT ALL RARELY OCCASIONALLY FREQUENTLY CONSTANTLY (never) (less than 1/10 of (less than 1/3 of the (1/3 to 2/3 of the (more than 2/3 of the time) time) time) the time)

12. Five ratings of physical demands are described below. Please mark the one which best describes your job.

Sedentary Sometimes I stand or walk, but I sit down most of the time. Occasionally, I lift up to a 10 pound load.

Light Any of the following may apply: -I walk or stand more than one third of the time -I often lift up to 10 pounds, sometimes up to 20 -I sit down, but often work foot pedal

Medium I often lift up to 20 pounds, or sometimes up to 50 pounds.

Heavy I often lift up to 50 pounds, or sometimes up to 100 pounds.

Very Heavy I often lift over 50 pounds, or sometimes over 100 pounds.

Page 2 of 2

37 ATTENDING PHYSICIAN'S RETURN TO WORK RECOMMENDATIONS

Employer:______

Employee Name:______

TO BE COMPLETED BY ATTENDING PHYSICIAN:

Diagnosis:______

Injury or Illness :______Work or Non-work related?______

I saw and treated this employee on (date)______and:

1.______Recommended his/her return to work with no limitations on (date)______2.______He/She may return to work capable of performing the degree of work checked below with the following limitations.

DEGREE LIMITATIONS

______Sedentary Work. Lifting 10 pounds maximum and 1. In a 10 hour work day patient may: occasionally lift and/or carrying such articles as dockets, a. Stand/Walk ledgers and small tools. Although a sedentary job is defined ____None ____4-6 Hours as one which involves sitting, a certain amount of walking ____1-4 Hours ____6-10 Hours and standing is often necessary in carrying out job duties. Jobs are sedentary if walking and standing are required b. Sit only occasionally and other sedentary criteria are met. ____1-3 Hours ____3-5 Hours ____5-10 Hours

______Light Work. Lifting 20 pounds maximum with frequent 2. Patient may use hands for repetitive actions such as: lifting and/or carrying of objects weighing up to 10 pounds. Simple Firm Fine Even though the weight lifted may be only a negligible Grasping Grasping Manipulating amount, a job is in this category when it requires walking or Right: __Yes__No __Yes__No __Yes__No standing to a significant degree or when it involves sitting Left: __Yes__No __Yes__No __Yes__No most of the time with a degree of pushing and pulling of arm and/or leg controls. 3. Patient may use feet for repetitive movement as in operating foot controls: __Yes__No ______Medium Light Work. Lifting 35 pounds maximum with frequent lifting and/or carrying of objects weighing up to 4. During work day, patient is able to: 30 pounds. 67-100% 34-66% 1-33% 0% a. Bend ______Medium Work. Lifting 50 pounds maximum with frequent b. Squat ______lifting and/or carrying of objects weighing up to 35 pounds. c. Climb ______d. Twist Body ______Heavy Work. Lifting 75 pounds maximum with frequent e. Push ______lifting and/or carrying of objects weighing up to 50 pounds. f. Pull ______g. Balance ______Very Heavy Work. Lifting objects in excess of 100 pounds h. Kneel ______with frequent lifting and/or carrying of objects weighing 75 i. Crawl ______pounds or more j. Grasp ______k. Reach ______

Other restrictions and/or limitations ______

3. These restrictions are in effect until (date)______or until employee is re-evaluated on (date)______.

4. He / She is totally incapacitated at this time. Employee will be re-evaluated on (date)______.

PHYSICIAN'S SIGNATURE______DATE:______(No rubber stamp, please)

38 DAILY OFFICE NOTES

Name ______Age_____BD______Injury Date ______1st visit______Dx: C-, T-, L, SI- Spr/str, _____IVDS, ______Rx: Spinal C, T, L, S, P; Levels: _O/1 C / T_ /; T-___ T/L Ant/PA; L-____; SI-L/R; NMR: Psoas, hamstring MFR: ______Complicating Factors: 1. Illness behavior; 2. Job dis.; 3. Past Hx of >4 episodes; 4. Symptoms > 1 wk; 5. Severe pain intensity; 6. New condition / injury related to pre-existing structural pathology or skeletal anomaly DATE ______/______/______VISIT # ______Ins.: WC; P; PI; HMO ______; PPO ______S. ( ) Improved ( ) No change ( ) Worse Osw. ______% NDI ______% ( ) Exacerbation % Improvement ______% Pain Scale: Now: _____/10; Ave.: _____/10; R: - /10 Comments:______O. ( ) Observation______( ) Palpation Pain/spasm______C- / TL- ROM: Fl______/4 Ext______/4 RLF______/4 LLF______/4 RR______/4 LR______/4 LOC______Ortho.:______Neuro.:______992 11, 12, 13, 14, 15: ______A. See above Dx ( ) S / O improved ( ) S / O no change ( ) S / O worse L / S Goal #______met Time w/ patient______min. ______P. See Rx at top of page; Lab, X-ray: C, T, L, 2, 3, 5, 7 NMR-PNF/MFR:CH, PIR, RI, Conc., eccen., Spr/Str.:C, T, L, Hamst, Psoas,_____ PT: IFC, LA-TX, ISTX, Man. Tx, Hot, Cold, , Kin.Act., Vib, Active Care: Ice/Heat; LB-/C-exer.; Proprio: Ball, WB, 1LS, BS, FCE, _____ 989-40, -41, -42;C:_____ T:_____ L:_____ P:______S:______Non SP 98943 -51:______(Dr: ______) ################################################################################################################## DATE ______/______/______VISIT # ______S. ( ) Improved ( ) No change ( ) Worse Osw. ______% NDI ______% ( ) Exacerbation % Improvement ______% Pain Scale: Now: _____/10; Ave.: _____/10; R: - /10 Comments:______O. ( ) Observation______( ) Palpation Pain/spasm______C- / TL- ROM: Fl______/4 Ext______/4 RLF______/4 LLF______/4 RR______/4 LR______/4 LOC______Ortho.:______Neuro.:______992 11, 12, 13, 14, 15: ______A. See above Dx ( ) S / O improved ( ) S / O no change ( ) S / O worse L / S Goal #______met Time w/ patient______min. ______P. See Rx at top of page; Lab, X-ray: C, T, L, 2, 3, 5, 7 NMR-PNF/MFR:CH, PIR, RI, Conc., eccen., Spr/Str.:C, T, L, Hamst, Psoas,_____ PT: IFC, LA-TX, ISTX, Man. Tx, Hot, Cold, , Kin.Act., Vib, Active Care: Ice/Heat; LB-/C-exer.; Proprio: Ball, WB, 1LS, BS, FCE, _____ 989-40, -41, -42;C:_____ T:_____ L:_____ P:______S:______Non SP 98943 -51:______(Dr: ______) ################################################################################################################## DATE ______/______/______VISIT # ______S. ( ) Improved ( ) No change ( ) Worse Osw. ______% NDI ______% ( ) Exacerbation % Improvement ______% Pain Scale: Now: _____/10; Ave.: _____/10; R: - /10 Comments:______O. ( ) Observation______( ) Palpation Pain/spasm______C- / TL- ROM: Fl______/4 Ext______/4 RLF______/4 LLF______/4 RR______/4 LR______/4 LOC______Ortho.:______Neuro.:______992 11, 12, 13, 14, 15: ______A. See above Dx ( ) S / O improved ( ) S / O no change ( ) S / O worse L / S Goal #______met Time w/ patient______min. ______P. See Rx at top of page; Lab, X-ray: C, T, L, 2, 3, 5, 7 NMR-PNF/MFR:CH, PIR, RI, Conc., eccen., Spr/Str.:C, T, L, Hamst, Psoas,_____ PT: IFC, LA-TX, ISTX, Man. Tx, Hot, Cold, , Kin.Act., Vib, Active Care: Ice/Heat; LB-/C-exer.; Proprio: Ball, WB, 1LS, BS, FCE, _____ 989-40, -41, -42;C:_____ T:_____ L:_____ P:______S:______Non SP 98943 -51:______(Dr: ______)

39

ABBREVIATION KEY FOR SOAP NOTE

Dx: Diagnosis: ): O=occiput; C=cervical; T=thoracic; L=lumbar; SI=sacroiliac; R=right; L=left; IVDS=intervertebral disc syndrome; Fix=fixation; Rx: Treatment (listed at top of the page): O=occiput; C=cervical; T=thoracic; L=lumbar; SI=sacroiliac; R=right; L=left; Ant.=anterior line of drive(LOD); PA=posterior to anterior (LOD); /= R/L LOD Complicating factors: Job dis.: Job dissatisfaction, (the rest are self-explanatory) (Note: the presence of any of these may extend the care beyond a condition’s expected natural history to resolve) SOAP: Subjective, Objective, Assessment, Plan

S. Subjective Ins.: Insurance WC: Worker’s Compensation P: Personal PI: Personal Injury claim HMO: Health maintenance organization PPO: Preferred Provider Organization Osw: Oswestry LBP disability questionnaire NDI: Neck Disability Index R: Range of pain on a 0-10 pain scale

O. Objective C- / TL-: Cervical or thoracolumbar; ROM: range of motion; Fl______/4: Flexion measurement pain / 0-4 scale LOC ____: Location of complaint Ortho: orthopedic exam; Neuro: neurological exam; 99211-99215=Evaluation/Management codes A. Assessment S/O improved: Subjectively &/or Objectively L/S Goal #___met: Long/short term goal #___met; Time w/ pt____min. = Time spent with the patient (__minutes)

P. Plan Rx: treatment; x-ray = spinal area C, T, L; 2, 3, 5, 7= no. of films/series; NMR (97112) = neuromuscular reeducation includes the following PNF ( Proprioceptive Neuromuscular Facilitation) techniques: CH: Contract-Hold Conc: Concentric stretch PIR: Post-isometric Rehabilitation Eccen.: Eccentric stretch RI: Reciprocal Inhibition Spr/Str: Spray and stretch

MFR (97250 or 97110): Myofascial Release (includes: trigger point therapy, longitudinal/transverse friction massage) Location NMR-PNF/MFR is applied: Spinal area: C, T, L; hamstring or (ilio-)psoas muscles PT: (the following are types of PT approaches) IFC (97014): Interferential Current LA-TX (97012): Long-axis cervical of lumbar traction ISTX (97012): Intersegmental traction Man.Tx (97122): Manual traction Hot/Cold (97010): Thermal therapy Kin.Act.( 97530): Kinetic Activity (billed per 15 minute units) Vib: Vibration therapy LB/C-: Low back and/or Cervical Proprioc.: Proprioception retraining (balance retraining by the use of balance board, shoes, etc.)

Active Care: LB: low back; C: cervical; exer: exercises; Proprio: proprioception techniques include: Ball: Physio-ball, WB: wobble board; 1 LS: one leg stand exercises; BS: balance shoes; FCE (97750): functional capacity eval. CMT codes: 98940 to 98942 (spinal manipulative codes): spinal areas (5 total) C, T, L, Pelvis (incl. SI), Sacrum; Non SP (non-spinal) codes: 98943(-51): includes head, TMJ, rib cage, upper/lower extremities, abdomen

40

X-RAY REPORT DOCUMENTATION

TEMPLATE for X-ray reporting: ______

Date:

Patient's name, address, birth date/age

X-ray study information: x-ray #, views included, date of x-ray, location x-rays taken, comparison views from past (indicate the x-ray ID number(s).

Dx and clinical information:

Findings reveal:

Impressions: (list numerically the highlights of the findings)

Signed by Dr. ______

EXAMPLE: LETTERHEAD (include clinic name, address, phone number)

June 30, 1998

Patient: Sample Patient (name/address) X-ray taken at YCC 6-29-98 BD: 2-26-59 Age: 39 X-ray #7537 Lumbar: AP, lateral

Dx: Acute onset (3 day duration), lumbar sprain/strain without radiculopathy (unresolving)

Findings reveal: Elevation right hemipelvis with 7mm left leg length deficiency, with a compensatory 6 degree sacral base unleveling inferior left. There is a 3 degree right lateral flexion malposition of T11 resulting in a 9 degree levorotoscoliosis, grade 1 pedicular drift, apexing left at L2. The sacral base angle is accentuated at 50 degrees and there is a marked, 5 cm anterior shift in the weight bearing line, supporting the presence of significant posterior facet overload preponderance at the lumbosacral junction. The IVD/IVF spacings are patent and free of clutter. There is no significant hip or SI joint pathology noted and the pubic symphysis is well aligned. There are no signs of fracture, dislocation and bone density appears normal.

Impressions: 1. Pelvic obliquity is quite significant with a 7mm left leg length deficiency, compensatory 6 degree sacral base unleveling to the left, setting up a T11 and S1, 9 degree levorotoscoliosis, grade 1 pedicular drift, apexing left at L3. 2. Accentuated sacral base angle at 50 degrees, and a 5cm anterior shift in the weight bearing line is supportive of facet overloading at the lumbosacral junction. 3. IVD/IVF spacings are patent and free of clutter. 4. There are no signs of fracture, dislocation and bone density appears adequate.

______Steven G. Yeomans, D.C., FACO

41

MACROS & BOILERPLATES

EXAMPLES:

1. HEALTH STATUS QUESTIONNAIRE: this is one of 4 Macros, which are different due to normative data for age/gender.

Female (65+) A general health status questionnaire was also performed. More specifically, the Health Status Questionnaire (HSQ-2.0 or SF-36) is a general health instrument which results in eight general health scales and three depression scales. The following table summarizes the results (right-hand column) which can be compared with a national average ("Mean" column). The bold printed areas represent the patient scores which fall below the mean, or average.

Baseline Re-exam Re-exam Re-exam Re-exam SCALE MEAN Initial #1 #2 #3 #4 Exam

1. HEALTH PERCEPTION 63.9

2. PHYSICAL FUNCTION 60.8

3. ROLE-PHYSICAL 51.6

4. ROLE-EMOTIONAL 72.5

5. SOCIAL FUNCTIONING 79.9

6. BODILY PAIN 66.4

7. MENTAL HEALTH 76.7

8. ENERGY FATIGUE 56.5

9. MAJOR DEPRESSION NA

10.DYSTHYMIA NA

11.BOTH 9 & 10 NA

2. GOALS AND PLAN MACRO

Short term goals include: 1. Reduce pain 50%, 14 days. 2. Decrease pain, increase ROM, 50%, 14 days. 3. Decrease muscle spasm, 50%, 14 days.

Long term goals include: 1. Functional restoration. 2. Initiate home/active care. 3. Rehabilitation/strengthening.

Plan: 1. CMT: 3x/wk., 2 wks., reassess and modify treatment if no change, or continue treatment 2 additional weeks and re-examine if benefits are noted. 2. Ice 15 min., on/off/on x 3 (1.25 hrs. total), t.i.d.-q.i.d. (cervical, thoracic, lumbar) spine. 3. Bed rest. 4. PT: Interferential 80-100 CPS, 10 min., (cervical, thoracic, lumbar) spine. 5. Exercise - TBA once treatment tolerances are determined. 6. ADL-work modifications: None/self administered (or______). 7. X-ray:______.

42

3. FOOT ORTHOTIC LETTER OF MEDICAL NECESSITY BOILERPLATE: The opening paragraph is case specific information regarding the clinical findings that necessitate the PLAN for foot orthotic fitting/casting.

Please be advised that the utilization of corrective prescription foot orthotics is medically necessary to control this condition. Corrective prescription foot orthotics are made initially from a plaster cast made from the person's feet at this office and then sent to a licensed podiatric laboratory, which in this case is Podiatric Art Labs in Pekin, IL (1-800-447-0151), where a positive cast is then made. The foot orthotics are fabricated to the positive cast which are then stored for 6 months and the foot orthotics are returned to this clinic where they are dispensed to the individual with specific instructions.

The cost of the corrective prescription foot orthotics at this facility is $350. This includes castings, fitting and modifications within the first 6 months. This compares to $450, which is charged at the podiatric clinic in this community.

Please reply as to the insurability of the corrective prescription foot orthotics in letter form, and if you have further questions or comments, please feel free to contact this office.

Sincerely,

______Steven G. Yeomans, D.C., FACO

SGY/

Macro Disc: Table of Contents(partial)

Name Of Saved Macro Description Of The Macro 1. Hsqa.cht Health Status Questionnaire Males 18-64 Years old 2. Hsqb.cht Health Status Questionnaire Females 18-64 Years old 3. Hsqc.cht Health Status Questionnaire Males 65+ Years old 4. Hsqd.cht Health Status Questionnaire Females 65+ Years old 5. Irsheet Impairment rating summary form 6. Macro.fo Foot orthotics "letter of medical necessity" macro 7. Macro.sfs spinal function sort 8. Macro.vas Triple VAS and outcome summary optional form 9. Prognosis.sca Forman & Croft's prognosis scale for cervical spine / 10. QFCE.cht QFCE summary chart macro 11. Routesli.bn Route slip 12. Spt.cht Static Position Tolerance test chart 13. Goals Goals and Plan (from SOAP note exam dictation) 14. Macro Narrative Opening Address, Regarding, Dear…., opening statement(s) 15. PE Vitals & Observation Initial exam information 16. PE - Palpation Narrative report paragraph for palpation 17. PE - Ranges of motion Narrative report paragraph for Ranges of motion 18. PE - Ortho C-Spine Narrative report paragraph for Ortho C-Spine 19. PE - Ortho L-Spine Narrative report paragraph for Ortho L-Spine 20. PE Neuro C-Spine Narrative report paragraph for Neuro C-Spine 21. PE Neuro L-Spine Narrative report paragraph for Neuro L-Spine 22. PE - X-ray Narrative report paragraph for X-ray 23. Assessment - Prognosis Narrative report paragraph for Assessment - Prognosis 24. Recommendations Narrative report paragraph for Recommendations 25. Future anticipated care Narrative report paragraph for Future anticipated care 26. Work Restrictions Narrative report paragraph for Work Restrictions 27. Closing statement(s) Narrative report paragraph for Closing statement(s)

CHAPTER 3 OUTCOME ASSESMENT MEASUREMENT DEVICES

43

QUADRUPLE VISUAL ANALOGUE SCALE

INSTRUCTIONS: Please circle the number that best describes the question being asked. NOTE: If you have more than one complaint, please answer each question for each individual complaint and indicate the score is for each complaint. Please indicate your average pain levels and pain at minimum / maximum using the last 3 months as your reference.

EXAMPLE:

headache neck low back worst no pain ______possible 0 1 2 3 4 5 6 7 8 9 10 pain

############################################################################################################

1. What is your pain RIGHT NOW? worst no pain ______possible 0 1 2 3 4 5 6 7 8 9 10 pain

2. What is your TYPICAL or AVERAGE pain? worst no pain ______possible 0 1 2 3 4 5 6 7 8 9 10 pain

3. What is your pain level AT ITS BEST (How close to “0” does your pain get at its best)? worst no pain ______possible 0 1 2 3 4 5 6 7 8 9 10 pain

What percentage of your awake hours is your pain at its best? ______%

4. What is your pain level AT ITS WORST (How close to “10” does your pain get at its worst)? worst no pain ______possible 0 1 2 3 4 5 6 7 8 9 10 pain

What percentage of your awake hours is your pain at its worst? ______%

NAME ______AGE______DATE______SCORE______

SCORE: #1 ______+ #2 ______+ #4 ______= ______/ 3 x 10 = ______(Low intensity = <50; High intensity = >50)

44 PAIN DRAWING

Name: ______Date: ______

Please be sure to fill this out extremely accurately. Mark the area on your body where you feel the described sensation(s). Use the appropriate symbol(s), mark areas of radiating pain, and include all affected areas. You may draw in the face as well.

Numbness ------Pins & ooooooo Burning xxxxxxxxx Stabbing /////////// Aching ((((((((( ------Needles ooooooo Pain xxxxxxxx Pain /////////// Pain ((((((((

VISUAL ANALOGUE SCALE

Please mark on the line the pain level that represents your greatest complaint:

NO PAIN: 0 1 2 3 4 5 6 7 8 9 10 UNBEARABLE PAIN

a) Right Now:---- 0 1 2 3 4 5 6 7 8 9 10 ______b) Average Pain 0 1 2 3 4 5 6 7 8 9 10 ______c) At Best ------0 1 2 3 4 5 6 7 8 9 10 ______d) At Worst------0 1 2 3 4 5 6 7 8 9 10 ______

45

NAME______AGE______DATE______DATE OF INJURY______

DECODED KEY: SEE INFORMATION ON LAST PAGE FOR SCORING

Health Status Questionnaire (HSQ-12) DECODED VERSION

1. In general, would you say your health is:

(circle one number) Recode Excellent...... ……. 1 100 Very Good...... …. 2 85 Good...... ……. 3 60 Fair...... ……… 4 25 Poor...... ……… 5 0

The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?

(circle one number on each line)

Yes, Yes, No, not limited limited limited a lot a little at all 2. Lifting or carrying groceries...... 1 2 3 0, 50, 100

3. Climbing several flights of stairs.. 1 2 3 0, 50, 100

4. Walking several blocks...... 1 2 3 0, 50, 100

5. During the past 4 weeks how much difficulty did you have doing your work or other regular daily activities as a result of your physical health? (circle one number)

None at all...... ……… 1 100 A little bit...... ………. 2 65 Moderately...... …….. 3 25 Quite a bit...... ……… 4 10 Couldn't do any work….. 5 0

6. During the past 4 weeks, to what extent have you accomplished less than you would like in your work or other daily activities as a result of emotional problems (such as feeling depressed or anxious)? (circle one number)

None at all...... ……… 1 100 A little bit...... ………. 2 65 Moderately...... …….. 3 45 Quite a bit...... ……… 4 20 Extremely...... …….. 5 0

46 7. During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups? (circle one number)

Recode Not at all...... ……….. 1 100 Slightly...... ……… 2 75 Moderately...... …….. 3 50 Quite a bit...... ………. 4 25 Extremely...... ……… 5 0

8. How much bodily pain have you had during the past 4 weeks?

(circle one number) None...... …………… 1 100 Very mild...... …………. 2 85 Mild...... ………….. 3 65 Moderate...... ………… 4 45 Severe...... …………. 5 25 Very severe.....…………. 6 0

These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling.

How much of the time during the past 4 weeks...

(circle one number on each line) All of Most A good Some Little None the the of bit of of the of the of the time time time time time time

9. Have you felt calm and peaceful? 1 2 3 4 5 6 100, 80, 60, 40, 20, 0

10. Did you have a lot of energy? 1 2 3 4 5 6 100, 80, 60, 40, 20, 0

11. Have you felt downhearted and blue? 1 2 3 4 5 6 0, 20, 40, 60, 80, 100

12. Have you been a happy person? 1 2 3 4 5 6 100, 80, 60, 40, 20, 0

TABLE 2: SECOND STEP: HSQ-12 Scoring Algorithms / 2nd step: Computing Scale Scores SCALE No. of Scale Items Minimum No. of Items Items needed to Compute a Score Physical Functioning 3 2, 3, 4 2 Role Limitations Attributable to: 1 5 1 Physical Health (Role-Physical) Bodily Pain 1 8 1 Health Perception 1 1 1 Energy / Fatigue 1 10 1 Social Functioning 1 7 1 Role Limitations Attributable to: Mental 1 6 1 Health (Role-Mental) Mental Health 3 9, 11, 12 2

47 SCORING THE HSQ-12

 Formula: Sum of Recoded Scale Item = Scale Score Number of Completed Scale Items

HSQ9+HSQ11+HSQ12 ______= Mental Health Score 3 LAST STEP: The average for each of the 8 categories is calculated and then transferred to the summary page. Example: # of items Question #’s Scores Total Average 1) Physical Function: n=3: 2-4: 50 + 100 + 0 = 150 / 3 50 2) Role-Physical: n=1: 5: 65 65 / 1 65       8) Mental Health: n=3: 9, 11, 12: 80 + 60 + 40 = 180 /3 60

______

RULES: 1. Step 1: Recode the response values from the instrument (use the recoding version) 2. Step 2: Calculate the average of the recoded response values for the multi-item scales (Scales 1 & 8) 3. The higher the score, the better the health status 4. Scoring may be completed manually with a calculator or with a standard data analysis and database management software (e.g., SAS, SPSS, FoxPro, dBASE). It is more efficient and reliable to enter the numbers corresponding to the specific response values into a spreadsheet or data entry package, allowing the computer to process the necessary calculations. 5. Missing responses for scales 1 & 8 can be estimated by averaging the 2 completed items and re-averaging (plugging in the average of the 2 into the missing 1 question slot). When a missing response from a single-item question occurs, the scale score it treated as missing. 6. Questions 13-15 are "Yes / No" questions and act as a screen for depression. When answered "Yes" inquiry as to the source of depression and follow-up with a psychometric tool (SCL-90R, Beck's Depression Inventory, etc.) and/or referral for a psychological consultation is recommended.

48

NAME______AGE______DATE______DATE OF INJURY______

Health Status Questionnaire (HSQ-12)

1. In general, would you say your health is:

(circle one number) Excellent...... ……. 1 Very Good...... …. 2 Good...... ……. 3 Fair...... ……… 4 Poor...... ……… 5

The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? (circle one number on each line) Yes, Yes, No, not limited limited limited a lot a little at all 2. Lifting or carrying groceries...... 1 2 3

3. Climbing several flights of stairs.. 1 2 3

4. Walking several blocks...... 1 2 3

5. During the past 4 weeks how much difficulty did you have doing your work or other regular daily activities as a result of your physical health? (circle one number)

None at all...... ……… 1 A little bit...... ………. 2 Moderately...... …….. 3 Quite a bit...... ……… 4 Couldn't do any work….. 5

6. During the past 4 weeks, to what extent have you accomplished less than you would like in your work or other daily activities as a result of emotional problems (such as feeling depressed or anxious)? (circle one number)

None at all...... ……… 1 A little bit...... ………. 2 Moderately...... …….. 3 Quite a bit...... ……… 4 Extremely...... …….. 5

49

7. During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups? (circle one number)

Not at all...... ……….. 1 Slightly...... ……… 2 Moderately...... …….. 3 Quite a bit...... ………. 4 Extremely...... ……… 5

8. How much bodily pain have you had during the past 4 weeks?

(circle one number) None...... …………… 1 Very mild...... …………. 2 Mild...... ………….. 3 Moderate...... ………… 4 Severe...... …………. 5 Very severe.....…………. 6

These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling.

How much of the time during the past 4 weeks... (circle one number on each line) All of Most A good Some Little None the the of bit of of the of the of the time time time time time time

9. Have you felt calm and peaceful? 1 2 3 4 5 6

10. Did you have a lot of energy? 1 2 3 4 5 6

11. Have you felt downhearted and blue? 1 2 3 4 5 6

12. Have you been a happy person? 1 2 3 4 5 6

Please answer YES or NO for each question by circling "1" or "2" on each line.

Yes No 13. In the past year, have you had 2 weeks or more during which you felt sad, blue or depressed; or when you lost all interest or pleasure in things that you usually cared about of enjoyed?.. 1 2

14. Have you had 2 years or more in your life when you felt depressed or sad most days, even if you felt okay sometimes?...... 1 2

15. Have you felt depressed or sad much of the time in the past year?...... 1 2

50

SF-12 HEALTH STATUS RESULTS

NAME______DATE______AGE______DOB______SEX M/F

SF-12 INITIAL 1st 2nd 3rd SCALE BASELINE MEAN* RE-exam RE-exam RE-exam 1. HEALTH PERCEPTION 72 2. PHYSICAL FUNCTION 84 3. ROLE-PHYSICAL 81 4. ROLE-EMOTIONAL 81 5. SOCIAL FUNCTIONING 83 6. BODILY PAIN 75 7. MENTAL HEALTH 75 8. ENERGY FATIGUE 61 Major Depression Yes / No Dysthymia Yes / No Both Yes / No * Not yet established (1996); the mean scores are those derived from the HSQ 2.0 (36 item questionnaire)

CIRCLE SUB-NORMAL SCORES (1-8)

SIGNED______DATE______

51

HEADACHE DISABILITY INDEX

NAME: ______DATE: ______AGE: ______Scores Total: ______; E____; F____ (100) (52) (48) INSTRUCTIONS: Please CIRCLE the correct response:

1. I have headache: [1] 1 per month [2] more than 1 but less than 4 per month [3] more than one per week 2. My headache is: [1] mild [2] moderate [3] severe

INSTRUCTIONS: (Please read carefully): The purpose of the scale is to identify difficulties that you may be experiencing because of your headache. Please check off “YES”, “SOMETIMES”, or “NO” to each item. Answer each question as it pertains to your headache only.

YES SOMETIMES NO E1. Because of my I feel handicapped. F2. Because of my headaches I feel restricted in performing my routine daily activities. E3. No one understands the effect my headaches have on my life. F4. I restrict my recreational activities (e.g. sports, hobbies) because of my headaches. E5. My headaches make me angry. E6. Sometimes I feel that I am going to lose control because of my headaches. F7. Because of my headaches I am less likely to socialize. E8. My spouse (significant other), or family and friends have no idea what I am going through because of my headaches. E9. My headaches are so bad that I feel I am going to go insane. E10. My outlook on the world is affected by my headaches. E11. I am afraid to go outside when I feel that a headache is starting. E12. I feel desperate because of my headaches. F13. I am concerned that I am paying penalties at work or at home because of my headaches. E14. My headaches place stress on my relationships with family or friends. F15. I avoid being around people when I have a headache. F16. I believe my headaches are making it difficult for me to achieve my goals in life. F17. I am unable to think clearly because of my headaches. F18. I get tense (e.g. muscle tension) because of my headaches. F19. I do not enjoy social gatherings because of my headaches. E20. I feel irritable because of my headaches. F21. I avoid traveling because of my headaches. E22. My headaches make me feel confused. E23. My headaches make me feel frustrated. F24. I find it difficult to read because of my headaches. F25. I find it difficult to focus my attention away from my headaches and on other things. Jacobson Gary P., Ramadan NM, et al., The Henry Ford Hospital headache disability inventory (HDI). Neurology 1994;44:837-842.

52

REVISED OSWESTRY LOW BACK PAIN DISABILITY QUESTIONNAIRE PLEASE READ: This questionnaire is designed to enable us to understand how much your low back pain has affected your ability to manage your everyday activities. Please answer each section by circling the ONE CHOICE that most applies to you. We realize that you may feel that more than one statement may relate to you, but PLEASE JUST CIRCLE THE ONE. CHOICE WHICH MOST CLOSELY DESCRIBES YOUR PROBLEM RIGHT NOW. SECTION 1 - Pain Intensity SECTION 6 - Standing A I can stand as long as I want without pain. A The pain comes and goes and is very mild. B I have some pain while standing, but it does not increase with time. B The pain is mild and does not vary much. C I cannot stand for longer than one hour without increasing pain. C The pain comes and goes and is moderate. D I cannot stand for longer than 1/2 hour without increasing pain. D The pain is moderate and does not vary much. E I cannot stand for longer than ten minute without increasing pain. E The pain comes and goes and is severe. F I avoid standing, because it increases the pain straight away. F The pain is severe and does not vary much. SECTION 2 - Personal Care SECTION 7 - Sleeping A I would not have to change my way of washing or in order to avoid pain. A I get no pain in bed. B I do not normally change my way of washing or dressing even B I get pain in bed, but it does not prevent me from sleeping well. though it causes some pain. C Because of pain, my normal night's sleep is reduced by less than C Washing and dressing increases the pain, but I manage not to one than one quarter. change my way of doing it. D Because of pain, my normal night's sleep is reduced by less than D Washing and dressing increases the pain and I find it necessary to one-half. change my way of doing it. E Because of pain, my normal night's sleep is reduced by less than E Because of the pain, I am unable to do some washing and dressing three-quarters. without help. F Pain prevents me from sleeping at all. F Because of the pain, I am unable to do any washing or dressing without help. SECTION 3 - Lifting SECTION 8 - Social Life A I can lift heavy weights without extra pain. B I can lift heavy weights, but it causes extra pain. A My social life is normal and gives me no pain. C Pain prevents me from lifting heavy weights off the floor. B My social life is normal, but increases the degree of my pain. D Pain prevents me from lifting heavy weights off the floor, but I C Pain has no significant effect on my social life apart from limiting can manage if they are conveniently positioned, eg. on a table. my more energetic interests, My e.g., dancing, etc. E Pain prevents me from lifting heavy weights, but I can manage D Pain has restricted my social life and I do not go out very often. light to medium weights if they are conveniently positioned. E Pain has restricted my social life to my home. F I can only lift very light weights, at the most. F I have hardly any social life because of the pain. SECTION 4 - Walking SECTION 9 - Traveling A I get no pain while traveling. A Pain does not prevent me from walking any distance. B I get some pain while traveling, but none of my usual forms of B Pain prevents me from walking more than one mile. travel make it any worse. C Pain prevents me from walking more than 1/2 mile. C I get extra pain while traveling, but it does not compel me to seek D Pain prevents me from walking more than 1/4 mile. alternative forms of travel. E I can only walk while using a cane or on crutches. D I get extra pain while traveling which compels me to seek F I am in bed most of the time and have to crawl to the toilet. alternative forms of travel. E Pain restricts all forms of travel. F Pain prevents all forms of travel except that done lying down. SECTION 5 - Sitting SECTION 10 - Changing Degree of Pain A My pain is rapidly getting better. A I can sit in any chair as long as I like without pain. B My pain fluctuates, but overall is definitely getting better. B I can only sit in my favorite chair as long as I like. C My pain seems to be getting better, but improvement is slow at C Pain prevents me from sitting more than one hour. present. D Pain prevents me from sitting more than 1/2 hour. D My pain is neither getting better nor worse. E Pain prevents me from sitting more than ten minutes. E My pain is gradually worsening. F Pain prevents me from sitting at all. F My pain is rapidly worsening.

COMMENTS: ______

NAME: ______DATE: ______SCORE: ______

Fairbank J, Davies J, et al. The Oswestry Low Back Pain Disability Questionnaire. Physiother 1980; 66(18): 271-273.

53 DISABILITY INDEX QUESTIONNAIRE PLEASE READ: This questionnaire is designed to enable us to understand how much your neck pain has affected your ability to manage your everyday activities. Please answer each section by circling the ONE CHOICE that most applies to you. We realize that you may feel that more than one statement may relate to you, but PLEASE JUST CIRCLE THE ONE. CHOICE WHICH MOST CLOSELY DESCRIBES YOUR PROBLEM RIGHT NOW. SECTION 1 - Pain Intensity SECTION 6 - Concentration

A I have no pain at the moment. A I can concentrate fully when I want to with no difficulty. B The pain is very mild at the moment. B I can concentrate fully when I want to with slight difficulty. C The pain is moderate at the moment. C I have a fair degree of difficulty in concentrating when I want to. D The pain is fairly severe at the moment. D I have a lot of difficulty in concentrating when I want to. E The pain is very severe at the moment. E I have a great deal of difficulty in concentrating when I want to. F The pain is the worst imaginable at the moment. F I cannot concentrate at all. SECTION 2 -Personal Care (Washing, Dressing, etc.) SECTION 7 - Work

A I can look after myself normally without causing extra pain. A I can do as much work as I want to. B I can look after myself normally, but it causes extra pain. B I can only do my usual work, but no more. C It is painful to look after myself and I am slow and careful. C I can do most of my usual work, but no more. D I need some help, but manage most of my personal care. D I cannot do my usual work. E I need help every day in most aspects of self care. E I can hardly do any work at all. F I do not get dressed, I wash with difficulty and stay in bed. F I cannot do any work at all.

SECTION 3 - Lifting SECTION 8 - Driving

A I can lift heavy weights without extra pain. A I can drive my car without any neck pain. B I can lift heavy weights, but it gives extra pain. B I can drive my car as long as I want with slight pain in my neck. C Pain prevents me from lifting heavy weights off the floor, but I C I can drive my car as long as I want with moderate pain in my can manage if they are conveniently positioned, for example, on a neck. table. D I cannot drive my car as long as I want because of moderate pain D Pain prevents me from lifting heavy weights, but I can manage in my neck. light to medium weights if they are conveniently positioned. E I can hardly drive at all because of severe pain in my neck. E I can lift very light weights. F I cannot drive my car at all. F I cannot lift or carry anything at all. SECTION 4 - Reading SECTION 9 - Sleeping

A I can read as much as I want to with no pain in my neck. A I have no trouble sleeping. B I can read as much as I want to with slight pain in my neck. B My sleep is slightly disturbed (less than 1 hour sleepless). C I can read as much as I want to with moderate pain in my neck. C My sleep is mildly disturbed (1-2 hours sleepless). D I cannot read as much as I want because of moderate pain in my D My sleep is moderately disturbed (2-3 hours sleepless). neck. E My sleep is greatly disturbed (3-5 hours sleepless). E I cannot read as much as I want because of severe pain in my F My sleep is completely disturbed (5-7 hours) neck. F I cannot read at all. SECTION 5 - Headaches SECTION 10 - Recreation A I am able to engage in all of my recreational activities with no neck A I have no headaches at all. pain at all. B I have slight headaches which come infrequently. B I am able to engage in all of my recreational activities with some C I have moderate headaches which come infrequently. pain in my neck. D I have moderate headaches which come frequently. C I am able to engage in most, but not all of my recreational E I have severe headaches which come frequently. activities because of pain in my neck. F I have headaches almost all the time. D I am able to engage in a few of my recreational activities because of pain in my neck. E I can hardly do any recreational activities because of pain in my neck. F I cannot do any recreational activities at all. COMMENTS:______

NAME: ______DATE: ______SCORE: ______

Vernon H, Mior S. The Neck Disability Index: A study of reliability and validity. J Manipulative Physiol Ther 1991;14:409-415.

54

SCORING TECHNIQUE FOR THE OSWESTRY LOW BACK DISABILITY QUESTIONNAIRE AND NECK DISABILITY INDEX 1. Each of the 10 sections is scored separately (0 to 5 points ea.) & added up (max. total = 50). EXAMPLE: Section 1. Pain Intensity Point Value A. ______I have no pain at the moment 0 B. ______The pain is very mild at the moment 1 C. ______The pain is moderate at the moment 2 D. ______The pain is fairly severe at the moment 3 E. ______The pain is very severe at the moment 4 F. ______The pain is the worst imaginable 5

2. If all 10 sections are completed, simply double the patients score. 3. If a section is omitted, divide the patient’s total score by the number of sections completed times 5.

FORMULA: PATIENT’S SCORE X 100 = ______% DISABILITY # OF SECTIONS COMPLETED X 5

EXAMPLE: If 9 of 10 sections are completed, divide the patient’s score by 9 X 5 = 45; if…….. Patient’s Score: 22 Number of sections completed: 9 (9 X 5 = 45) 22/45 X 100 = 48 % disability 4. Interpretation of disability scores (from original article): SCORE INTERPRETATION OF THE OSWESTRY LBP DISABILITY QUESTIONNAIRE 0-20% Can cope w/ most ADL’s. Usually no treatment needed, apart from advice on lifting, Minimal sitting, posture, physical fitness and diet. In this group, some patients have particular Disability difficulty with sitting and this may be important if their occupation is sedentary (typist, driver, etc.) 20-40% This group experiences more pain and problems with sitting, lifting and standing. Travel Moderate and social life are more difficult and they may well be off work. Personal care, sexual Disability activity and sleeping are not grossly affected, and the back condition can usually be managed by conservative means.

40-60% Pain remains the main problem in this group of patients by travel, personal care, social Severe life, sexual activity and sleep are also affected. These patients require detailed Disability investigation.

60-80% Back pain impinges on all aspects of these patients’ lives both at home and at work. Crippled Positive intervention is required.

80-100% These patients are either bed-bound or exaggerating their symptoms. This can be evaluated by careful observation of the patient during the medical examination.

55 Global Impression of Change

Since the start of my care at the clinic, my overall status is:

1. □ Very Much Improved

2. □ Much Improved

3. □ Minimally Improved

4. □ No Change

5. □ Minimally Worse

6. □ Much Worse

7. □ Very Much Worse

Name ______Signature ______Date ______

Farra JT, Young JP, LaMoureauz L, Werth JL, Poole RM. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain 2001;94:149-158.

Hagg O. Fritzell P:, Nordwall A. The clinical importance of changes in outcome scores after treatment for chronic low back pain. Eur Spine J 2003;12:12-20.

56 The BACK Bournemouth Questionnaire

The following scales have been designed to find out about your back pain and how it is affecting you. Please answer ALL the scales by circling ONE number on EACH scale that best describes how you feel:

1. Over the past week, on average, how would you rate your back pain? No pain Worst pain possible 0 1 2 3 4 5 6 7 8 9 10

2. Over the past week, how much has your back pain interfered with your daily activities (housework, washing, dressing, walking, climbing stairs, getting in/out of bed/chair)?

No interference Unable to carry out activity 0 1 2 3 4 5 6 7 8 9 10

3. Over the past week, how much has your back pain interfered with your ability to take part in recreational, social, and family activities? No interference Unable to carry out activity 0 1 2 3 4 5 6 7 8 9 10

4. Over the past week, how anxious (tense, uptight, irritable, difficulty in concentrating/relaxing) have your been feeling? Not at all anxious Extremely anxious 0 1 2 3 4 5 6 7 8 9 10

5. Over the past week, how depressed (down-in-the-dumps, sad, in low spirits, pessimistic, unhappy) have you been feeling? Not at all depressed Extremely depressed 0 1 2 3 4 5 6 7 8 9 10

6. Over the past week, how have you felt your work (both inside and outside the home) has affected (or would affect) your back pain? Have made it no worse Have made it much worse 0 1 2 3 4 5 6 7 8 9 10

7. Over the past week, how much have you been able to control (reduce/help) your back pain on your own? Completely control it No control whatsoever 0 1 2 3 4 5 6 7 8 9 10

Patient name ______Patient signature ______Date ______

57 The Neck Bournemouth Questionnaire

The following scales have been designed to find out about your neck pain and how it is affecting you. Please answer ALL the scales by circling ONE number on EACH scale that best describes how you feel:

1. Over the past week, on average, how would you rate your neck pain? No pain Worst pain possible 0 1 2 3 4 5 6 7 8 9 10

2. Over the past week, how much has your neck pain interfered with your daily activities (housework, washing, dressing, lifting, reading, driving)?

No interference Unable to carry out activity 0 1 2 3 4 5 6 7 8 9 10

3. Over the past week, how much has your neck pain interfered with your ability to take part in recreational, social, and family activities? No interference Unable to carry out activity 0 1 2 3 4 5 6 7 8 9 10

4. Over the past week, how anxious (tense, uptight, irritable, difficulty in concentrating/relaxing) have your been feeling? Not at all anxious Extremely anxious 0 1 2 3 4 5 6 7 8 9 10

5. Over the past week, how depressed (down-in-the-dumps, sad, in low spirits, pessimistic, unhappy) have you been feeling? Not at all depressed Extremely depressed 0 1 2 3 4 5 6 7 8 9 10

6. Over the past week, how have you felt your work (both inside and outside the home) has affected (or would affect) your neck pain? Have made it no worse Have made it much worse 0 1 2 3 4 5 6 7 8 9 10

7. Over the past week, how much have you been able to control (reduce/help) your neck pain on your own? Completely control it No control whatsoever 0 1 2 3 4 5 6 7 8 9 10

Patient name ______Patient signature ______Date ______

58 PATIENT SPECIFIC FUNCTIONAL AND PAIN SCALES (PSFS)

Name ______Date______

In your visits here we want to know what 3 activities in your life you are unable to do or having the most difficulty with as a result of your chief problem.

Please list 3 activities you are unable to perform or having the most difficulty with because of your chief problem.

1. ______

2. ______

3. ______

Activity #1 (Circle one number):

0 1 2 3 4 5 6 7 8 9 10 Unable Able to perform to perform activity at same activity level as before injury or problem Activity #2 (Circle one number):

0 1 2 3 4 5 6 7 8 9 10 Unable Able to perform to perform activity at same activity level as before injury or problem Activity #3 (Circle one number):

0 1 2 3 4 5 6 7 8 9 10 Unable Able to perform to perform activity at same activity level as before injury or problem

Our goal is to work together with you to “problem-solve” ways to return you to the activities which you have told us you are either unable to perform or are giving you the most difficulty since this problem began.

Chatman AB, Hyams SP, Neel JM, Binkley JM, Stratford PW, Schomberg A, Stabler M. The patient-specific functional scale: Measurement properties in patients with knee dysfunction. Phys Ther 1997;77:820-829

59 The Chiropractic Satisfaction Questionnaire

NAME (Optional) ______DATE ______DO 1ST VISIT______DOI ______

The following questions are in reference to the treatment you have had in the past. Please circle the number which best reflects your satisfaction for each of the following (Circle one number on each line):

Very Poor Fair Good Very Excel The Poor Good Best

1. The amount of privacy you were given 1 2 3 4 5 6 7

2. Interest shown in you as a person 1 2 3 4 5 6 7

3. Friendliness, warmth, and personal manner of the 1 2 3 4 5 6 7 chiropractor who treated you

4. Explanations of treatment 1 2 3 4 5 6 7

5. Willingness to listen 1 2 3 4 5 6 7

6. Understanding your health problem 1 2 3 4 5 6 7

7. Answers given to your questions 1 2 3 4 5 6 7

8. Amount of time spent with you 1 2 3 4 5 6 7

9. Cost of care to you 1 2 3 4 5 6 7

10. Skill and ability of the chiropractor 1 2 3 4 5 6 7

11. Advice about ways to avoid illness and stay healthy 1 2 3 4 5 6 7

12. Ability of the chiropractor to put you at ease 1 2 3 4 5 6 7

13. Courtesy, politeness, and respect shown by the 1 2 3 4 5 6 7 chiropractor.

14. Care received overall 1 2 3 4 5 6 7

Other Comments? ______

Note: To score, first average responses to each item to obtain a score ranging between 1 and 7. Second, subtract 1 from the average. Then divide the result by 6 and multiply by 100.

60

Beck's Depression Inventory Name:______Date: ______BD: ______Please circle the number next to the answer that best reflects how you have felt the past few days. Try to complete all 21 questions. 1. 0 I do not feel sad 12 0 I have not lost interest in other people 1 I feel sad 1 I am less interested in other people than I used to be 2 I am sad all of the time and I can't snap out of it 2 I have lost most of my interest in other people 3 I am so sad or unhappy that I can't stand it 3 I have lost all of my interest in other people

2. 0 I am not particularly discouraged about the future 13 0 I make decisions about as well as I ever could 1 I feel discouraged about the future 1 I put off making decisions more than I used to 2 I feel I have nothing to look forward to 2 I have greater difficulty in making decisions than before 3 I feel that the future is hopeless and that things cannot 3 I can't make decisions at all anymore improve

3. 0 I do not feel like a failure 14 0 I don't feel that I look any worse than I used to 1 I feel I have failed more than the average person 1 I am worried that I am looking old or unattractive 2 As I look back on my life, all I can see is a lot of failures 2 I feel that there are permanent changes in my appearance 3 I feel I am a complete failure as a person that make me look unattractive 3 I believe that I look ugly 4. 0 I get as much satisfaction out of things as I used to 15 0 I can work about as well as before 1 I don't enjoy things the way I used to 1 It takes an extra effort to get started at doing something 2 I don't get real satisfaction out of anything anymore 2 I have to push myself very hard to do anything 3 I am dissatisfied or bored with everything 3 I can't do any work at all

5. 0 I don't feel particularly guilty 16 0 I can sleep as well as usual 1 I feel guilty a good part of the time 1 I don't sleep as well as I used to 2 I feel quite guilty most of the time 2 I wake up 1-2 hours earlier than usual and find it hard to 3 I feel guilty all of the time get back to sleep 3 I wake up several hours earlier than I used to and cannot get back to sleep

6. 0 I don't feel I am being punished 17 0 I don't get more tired than usual 1 I feel I may be punished 1 I get tired more easily than I used to 2 I expect to be punished 2 I get tired from doing almost anything 3 I feel I am being punished 3 I am too tired to do anything

7. 0 I don't feel disappointed in myself 18 0 My appetite is no worse than usual 1 I am disappointed in myself 1 My appetite is not as good as it used to be 2 I am disgusted with myself 2 My appetite is much worse now 3 I hate myself 3 I have no appetite at all anymore

8. 0 I don't feel any worse than anybody else 19 0 I haven't lost much weight, if any, lately 1 I am critical of myself for my weaknesses or mistakes 1 I have lost more than five pounds 2 I blame myself all the time for my faults 2 I have lost more than ten pounds 3 I blame myself for everything bad that happens 3 I have lost more than fifteen pounds

9. 0 I don't have any thoughts of killing myself 20 0 I am no more worried about my health than usual 1 I have thoughts of killing myself, but I would not carry 1 I am worried about physical problems such as aches and them out pains, or upset stomach, or constipation 2 I would like to kill myself 2 I am very worried about physical problems and it's hard to 3 I would kill myself if I had the chance think of much else 3 I am so worried about my physical problems that I cannot think about anything else 10. 0 I don't cry any more than usual 1 I cry more now than I used to 21 0 I have not noticed any recent change in my interest in sex 2 I cry all the time now 1 I am less interested in sex than I used to be 3 I used to be able to cry, but now I can't cry even though I 2 I am much less interested in sex now want to 3 I have lost interest in sex completely

11. 0 I am no more irritated by things than I ever am 1 I am slightly more irritated now than usual 2 I am quite annoyed or irritated a good deal of the time 3 I feel irritated all the time now 61

Scoring and Interpretation of the Beck Depression Inventory

There is a 0-3 possible score for each of a total of 21 items, yielding a maximum possible total score of 63 points if all items are completed. Simply add up the total points and compare it to the following interpretation scale:

Total Score Levels of Depression *

1-10 These ups and downs are considered normal

11-16 Mild mood disturbance

17-20 Borderline clinical depression

21-30 Moderate depression

31-40 Severe depression

Over 40 Extreme depression

*A persistent score of 17 or higher upon repeat assessments may be suggestive of the need for professional treatment.

62 Yellow Flag Questionnaire

NAME ______Primary complaint - ______

1. Please indicate your usual level of pain during the past week: No pain 0 1 2 3 4 5 6 7 8 9 10 Worst possible pain

2. Does pain, numbness, tingling or weakness extend into your leg (from the low back) &/or arm (from the neck)? None of the time 0 1 2 3 4 5 6 7 8 9 10 All of the time

3. How would you rate your general health? (10-x) Poor 0 1 2 3 4 5 6 7 8 9 10 Excellent

4. If you had to spend the rest of your life with your condition as it is right now, how would you feel about it? Delighted 0 1 2 3 4 5 6 7 8 9 10 Terrible

5. How anxious (eg. tense, uptight, irritable, fearful, difficulty in concentrating / relaxing) you have been feeling during the past week: Not at all 0 1 2 3 4 5 6 7 8 9 10 Extremely anxious

6. How much you have been able to control (i.e., reduce/help) your pain/complaint on your own during the past week: I can reduce it 0 1 2 3 4 5 6 7 8 9 10 I can't reduce it at all

7. Please indicate how depressed (eg. Down-in-the-dumps, sad, downhearted, in low spirits, pessimistic, feelings of hopelessness) you have been feeling in the past week: Not depressed at all 0 1 2 3 4 5 6 7 8 9 10 Extremely depressed

8. On a scale of 0 to 10, how certain are you that you will be doing normal activities or working in six months? Very certain 0 1 2 3 4 5 6 7 8 9 10 Not certain at all

9. I can do light work for an hour? Completely agree 0 1 2 3 4 5 6 7 8 9 10 Completely disagree

10. I can sleep at night Completely agree 0 1 2 3 4 5 6 7 8 9 10 Completely disagree

11. An increase in pain is an indication that I should stop what I am doing until the pain decreases. Completely disagree 0 1 2 3 4 5 6 7 8 9 10 Completely agree

12. Physical activity makes my pain worse? Completely disagree 0 1 2 3 4 5 6 7 8 9 10 Completely agree

13. I should not do my normal activities including work with my present pain. Completely disagree 0 1 2 3 4 5 6 7 8 9 10 Completely agree

Please sign your name ______Date ______(v.4/2008) 63 SCORING SHEET: YELLOW FLAGS QUESTIONNAIRE

NAME ______DOB / AGE ______

Question Score Dates: PAIN 1 Usual level of pain (0-10) this week (score is # circled) 2 Frequency of radiating pain (0-10) (score is # circled) PSYCHO-SOCIAL 3 Self-rated health (0-10) (score is 10 - # circled)

4 Symptom satisfaction (0-10) (score is # circled)

5 Anxiety (0-10) (score is # circled)

6 Locus of control (0-10) (score is # circled) f

7 Depression (0-10) (score is # circled)

8 Ability to work 6 mo. from now (0-10) (score is # circled) FUNCTION 9 Light work tolerant for 1 hour (0-10) (score is # circled) 10 Can sleep at night (0-10) (score is # circled)

PSYCHO-SOCIAL (Fear-avoidance) 11 Pain = stop activity (0-10) (score is # circled)

12 Physical activity = worse pain (0-10) (score is # circled) 13 Should not do normal duty? (0-10) (score is # circled) TOTAL PAIN SCORE TOTAL PSYCHO-SOCIAL SCORE TOTAL FUNCTION SCORE TOTAL FEAR-AVOIDANCE SCORE CORE TOTAL SCORE

Scoring & Risk (Core Total): Low risk of chronic disability – under 55 points Moderate risk of chronic disability – 55 to 65 points High risk of chronic pain and disability – over 65 points 64

OUTCOMES ASSESSMENT RECORD

DATE PAIN FUNCTION

VAS Options: Options: VAS VAS &LB (Miscell.) Pain & Disability: Patient a. Now Drawing 1. UE 1. Headache Neck Satisfaction b. Ave. 2. CTS 2. Dizziness Disability  Oswestry 3. Shoulder 3. SCL-90R c. Range (NDI)  Roland M 4. Knee 4. ______CC______BASELINE a._____/10 Physiological 1. ______% 1. T____; E____ a.______/10 a.______/10 2. Sx____% Fnctn______b. ______/10 b. ______/10 b. _____/10 1. Yes 2. T_____;P______/____/___ Fn____% F_____;E____ c.___- ___/10 c.___- ___/10 c.___- ___/10 2. No 3. ______% 3. A_____;D____ 4. ______% 4. ______% ______% PROGRESS a._____/10 Physiological 1. ______% 1. T____; E____ a.______/10 a.______/10 2. Sx____% Fnctn______b. ______/10 b. ______/10 b. _____/10 1. Yes 2. T_____;P______/____/___ Fn____% F_____;E____ c.___- ___/10 c.___- ___/10 ______% c.___- ___/10 2. No 3. ______% 3. A_____;D____ 4. ______% 4. ______% ______% a._____/10 Physiological 1. ______% 1. T____; E____ a.______/10 a.______/10 2. Sx____% Fnctn______b. ______/10 b. ______/10 b. _____/10 1. Yes 2. T_____;P______/____/___ Fn____% F_____;E____ c.___- ___/10 c.___- ___/10 ______% c.___- ___/10 2. No 3. ______% 3. A_____;D____ 4. ______% 4. ______% ______% a._____/10 Physiological 1. ______% 1. T____; E____ a.______/10 a.______/10 2. Sx____% Fnctn______b. ______/10 b. ______/10 b. _____/10 1. Yes 2. T_____;P______/____/___ Fn____% F_____;E____ c.___- ___/10 c.___- ___/10 ______% c.___- ___/10 2. No 3. ______% 3. A_____;D____ 4. ______% 4. ______% ______% a._____/10 Physiological 1. ______% 1. T____; E____ a.______/10 a.______/10 2. Sx____% Fnctn______b. ______/10 b. ______/10 b. _____/10 1. Yes 2. T_____;P______/____/___ Fn____% F_____;E____ c.___- ___/10 c.___- ___/10 ______% c.___- ___/10 2. No 3. ______% 3. A_____;D____ 4. ______% 4. ______% ______% a._____/10 Physiological 1. ______% 1. T____; E____ a.______/10 a.______/10 2. Sx____% Fnctn______b. ______/10 b. ______/10 b. _____/10 1. Yes 2. T_____;P______/____/___ Fn____% F_____;E____ c.___- ___/10 c.___- ___/10 ______% c.___- ___/10 2. No 3. ______% 3. A_____;D____ 4. ______% 4. ______% ______%

DISCHARGE a._____/10 Physiological 1. ______% 1. T____; E____ a.______/10 a.______/10 ___/____/___ 2. Sx____% Fnctn______b. ______/10 b. ______/10 b. _____/10 1. Yes 2. T_____;P____ Fn____% F_____;E____ c.___- ___/10 c.___- ___/10 ______% c.___- ___/10 2. No 3. ______% 3. A_____;D____ 4. ______% 4. ______% ______% Key: VAS visual analogue scale; CC ; UE upper extremity; CTS carpal tunnel syndrome; SCL-90-R Symptom checklist 90-revised; NDI Neck disability index; LB low back; Sx Symptoms; Fn Function

NAME: ______DATE: ______DOA:______AGE/BD______

65 OUTCOMES ASSESSMENT RECORD

DATE PAIN FUNCTION

VAS VAS Health Neck % Cervical Drawing a. Now Status Disability Improve- Patient a. Now b. Ave. circle: SF-36 (NDI) ment Satisfaction b. Ave. c. Range HSQ, COOP (subj) c. Range BASELINE Initial Cervical Physiological R-Knee See separate Presentation a. 4-5/10 1. Yes a. 2/10 report b. 4-5/10 b. 2/10 Knee Q.= 35% 26 % NA 3/17/97 c. 0-5/10 c. 0-6/10 Shlder Q=28% PROGRESS a. 0/10 Physiological R-Knee See separate 4/16/97 b. 0-2/10 1. Yes a. 0/10 report 1. C-30% c. 0-5/10 b. 0-2/10 22 % 2. R Shlder NA c. 0-3/10 20% Knee Q.= 30% 3. R Knee Shlder Q=22% 60-70% a. 0/10 Physiological R-Knee See separate 6-2-97 b. 0-2/10 1. Yes a. 0/10 report (6-19-97) 1. C-50% Knee is c. 0-2/10 b. 4-6/10 18% 2. R Shlder 100 % reported as c. 0-8/10 30% primary Knee Q.= 56% 3. R Knee complaint Shlder Q=18% 20% a. 0/10 Physiological R-Knee See separate 7-16-97 b. 0-1/10 1. Yes a. 0/10 report 1. C-60% Pt received c. 0-2/10 b. 2-4/10 14% 2. R Shlder 100 % cortisone c. 0-5/10 50% shot in knee Knee Q.= 32% 3. R Knee Shlder Q=15% 40% a. 0/10 Physiological R-Knee See separate 8-15-97 b. 0-1/10 1. Yes a. 0/10 report 1. C-70% c. 0-2/10 b. 2-3/10 10% 2. R Shlder 100 % c. 0-4/10 50% Knee Q.= 22% 3. R Knee Shlder Q=12% 50% a. 0/10 Physiological R-Knee See separate 10-22-97 b. 0-1/10 1. Yes a. 0/10 report 1. C-75% c. 0-2/10 b. 2-3/10 8% 2. R Shlder 100 % Sent for c. 0-4/10 40% cortisone Knee Q.= 20% 3. R Knee shot shoulder Shlder Q=18% 40%

DISCHARGE a. 0/10 Physiological R-Knee See separate 2-4-98 b. 0-1/10 1. Yes a. 0/10 report 1. C-75% c. 0-2/10 b. 3-4/10 10% 2. R Shlder 100 % D/C with c. 0-5/10 50-60% PI=14% WP Knee Q.= 18% 3. R Knee Shlder Q=12% 50%

NAME: ______DATE: ______DOA:______AGE/BD______

66

NAME______PHYSICAL THERAPY DATE THERAPY AREA /SETTING / DATE THERAPY AREA /SETTING / notes notes HOT HOT IFC IFCCOLD COLD US USLA-TX LA-TX GALV GALVIS-TX IS-TX MSTIM MSTIM HOT HOT IFC IFCCOLD COLD US USLA-TX LA-TX GALV GALVIS-TX IS-TX MSTIM MSTIM HOT HOT IFC IFCCOLD COLD US USLA-TX LA-TX GALV GALVIS-TX IS-TX MSTIM MSTIM HOT HOT IFC IFCCOLD COLD US USLA-TX LA-TX GALV GALVIS-TX IS-TX MSTIM MSTIM HOT HOT IFC IFCCOLD COLD US USLA-TX LA-TX GALV GALVIS-TX IS-TX MSTIM MSTIM HOT HOT IFC IFCCOLD COLD US USLA-TX LA-TX GALV GALVIS-TX IS-TX MSTIM MSTIM HOT HOT IFC IFCCOLD COLD US USLA-TX LA-TX GALV GALVIS-TX IS-TX MSTIM MSTIM HOT HOT IFC IFCCOLD COLD US USLA-TX LA-TX GALV GALVIS-TX IS-TX MSTIM MSTIM HOT HOT IFC IFCCOLD COLD US USLA-TX LA-TX GALV GALVIS-TX IS-TX MSTIM MSTIM HOT HOT IFC IFCCOLD COLD US USLA-TX LA-TX GALV GALVIS-TX IS-TX MSTIM MSTIM HOT HOT IFC IFCCOLD COLD US USLA-TX LA-TX GALV GALVIS-TX IS-TX MSTIM MSTIM HOT HOT IFC IFCCOLD COLD US USLA-TX LA-TX GALV GALVIS-TX IS-TX MSTIM MSTIM HOT HOT IFC IFCCOLD COLD US USLA-TX LA-TX GALV GALVIS-TX IS-TX MSTIM MSTIM HOT HOT IFC IFCCOLD COLD US USLA-TX LA-TX GALV GALVIS-TX IS-TX MSTIM MSTIM HOT HOT IFC IFCCOLD COLD US USLA-TX LA-TX GALV GALVIS-TX IS-TX MSTIM MSTIM

67

Name/Address: Phone #'s: Insurance info: (see photocopy)

______Day time: ______

______Evening: ______

______Fax: ______

X-ray # SS#: Spousal information:

______Name: ______

SS#: ______

INSURANCE CARD PHOTOCOPY DRIVER'S LICENSE PHOTO COPY

NUTRITION / MEDICATION / BRACE-ORTHOTIC LOG

DATE Nutrition / Dose / DATE Nutrition / Dose / Medication / Recommendations Medication / Recommendations Brace-orthotic Brace-orthotic

68 PHOTOCOPY LOG DATE Copied for: DATE Copied for:

69

Upper Extremity Functional Index

Name______Date______DOI______(Key: LEFT/RIGHT)

We are interested in knowing whether you are having any difficulty at all with the activities listed below because of your upper limb problem for which you are currently seeking attention. Please check (√) an answer for each activity.

Today, do you or would you have any difficulty at all with: 0 1 2 3 4 Extreme Difficulty Or Unable Quite a Bit A Little to Perform of Moderate Bit of No Activities Activity Difficulty Difficulty Difficulty Difficulty 1) Any of your usual work, household, or school activities 2) Your usual hobbies, recreational or sporting activities 3) Lifting a bag of groceries to waist level 4) Lifting a bag of groceries above your Head 5) Grooming your hair 6) Pushing up on your hands (e.g., from bathtub or chair) 7) Preparing food (e.g., peeling, cutting) 8) Driving 9) Vacuuming, sweeping, or raking 10) Dressing 11) Doing up buttons 12) Using tools or appliances 13) Opening doors 14) Cleaning 15) Tying or lacing shoes 16) Sleeping 17) Laundering clothes (e.g., washing, ironing, folding) 18) Opening a jar 19) Throwing a ball 20) Carrying a small suitcase with your affected limb)

Stratford PW, Binkley JM, Stratford DM. Development and initial validation of the upper extremity functional index. Physiotherapy Canada Fall 2001;259-266. Score /80 MDC (minimum detectable change) = 9 pts /15% Error +/- 5 scale points

70

2) If Prior Treatment: Patient’s Global Impression of Change (PGIC):

Since beginning treatment at this clinic, how would you describe the change (if any) in ACTIVITY LIMITATIONS, SYMPTOMS, EMOTIONS, and OVERALL QUALITY OF LIFE, related to your painful condition? (Circle one number): Much Better No Change Much Worse ______0 1 2 3 4 5 6 7 8 9 10

Hurst H, Bolton J. Assessing the clinical significance of change scores recorded on subjective outcome measures. J Manipulative Physiol Ther 2004;27:26-35

3) Pain Level (QVAS): Right Now: ______/ 10; Usual / Typical: ______/ 10; At Best: ______/ 10; At Worst: ______/ 10 (Von Korff, 2000)

71

Lower Extremity Functional Scale

Name______Date______DOI______(Key: LEFT/RIGHT)

We are interested in knowing whether you are having any difficulty at all with the activities listed below because of your lower limb problem for which you are currently seeking attention. Please check (√) an answer for each activity.

Today, do you or would you have any difficulty at all with: 0 1 2 3 4 Extreme Difficulty Or Unable Quite a Bit A Little to Perform of Moderate Bit of No Activities Activity Difficulty Difficulty Difficulty Difficulty 1) Any of your usual work, household, or school activities 2) Your usual hobbies, recreational or sporting activities 3) Getting into or out of the bath 4) Walking between rooms 5) Putting on your shoes or socks 6) Squatting 7) Lifting an object, like a bag of groceries from the floor 8) Performing light activities around your Home 9) Performing heavy activities around your Home 10) Getting into or out of a car 11) Walking 2 blocks 12) Walking a mile 13) Going up or down 10 stairs (about 1 flight of stairs) 14) Standing for 1 hour 15) Sitting for 1 hour 16) Running on even ground 17) Running on uneven ground 18) Making sharp turns while running 19) Hopping 20) Rolling over in bed

Binkley JM, Stratford POW, Lott SA, Riddle DL. The lower extremity functional scale (LEFS): Scale development, measurement properties, and clinical application. Physical Therapy 1999;79:371-383.

Score /80 MDC (minimum detectable change) = 9 pts /15% Error +/- 5 scale points

72

2) If Prior Treatment: Patient’s Global Impression of Change (PGIC):

Since beginning treatment at this clinic, how would you describe the change (if any) in ACTIVITY LIMITATIONS, SYMPTOMS, EMOTIONS, and OVERALL QUALITY OF LIFE, related to your painful condition? (Circle one number): Much Better No Change Much Worse ______0 1 2 3 4 5 6 7 8 9 10

Hurst H, Bolton J. Assessing the clinical significance of change scores recorded on subjective outcome measures. J Manipulative Physiol Ther 2004;27:26-35

3) Pain Level (QVAS): Right Now: ______/ 10; Usual / Typical: ______/ 10; At Best: ______/ 10; At Worst: ______/ 10 (Von Korff, 2000)

73 BUSINESS ASSOCIATE AGREEMENT

This Business Associate Agreement (“Agreement”), dated ______, 201_, is entered into by and between ______(“Covered Entity”) and ______(the “Business Associate”) (each a “Party” and collectively the “Parties”), and is made a part of that certain service agreement or service agreements between the parties (the “Service Agreement”) pursuant to which Business Associate provides a service or services to Covered Entity that involves the use and/or disclosure of Covered Entity Protected Health Information (“PHI”).

NOW, THEREFORE, for good and valuable consideration, the sufficiency of which we hereby acknowledge, the Parties agree as follows:

I. DEFINITIONS:

A. Terms used but not otherwise defined in this Agreement shall have the same meaning as the meaning ascribed to those terms in the Health Information Portability and Accountability Act of 1996, as codified at 42 U.S.C. § 1320d (“HIPAA”), the Health Information Technology Act of 2009, as codified at 42 U.S.C.A. prec. § 17901 (“HITECH Act”), and any current and future regulations promulgated under HIPAA or the HITECH Act (HIPAA, HITECH Act and any current and future regulations promulgated under either are referred to as the “Regulations”).

B. Protected Health Information or PHI. “Protected Health Information” or “PHI” shall have the same meaning as the term “Protected Health Information” in 45 CFR 160.103, limited to the information created or received by Business Associate from or on behalf of Covered Entity, including, but not limited to electronic PHI.

II. OBLIGATIONS OF BUSINESS ASSOCIATE

In order that Covered Entity and Business Associate may achieve and maintain compliance with the requirements of HIPAA, Business Associate agrees:

A. To only use and disclose PHI as permitted by this Agreement or as Required By Law. Business Associate may 1) use and disclose PHI to perform its obligations as set forth in the Service Agreement; (2) use PHI for the proper management and administration of Business Associate or to carry out its legal responsibilities; (3) disclose PHI for the proper management and administration of Business Associate or to carry out its legal responsibilities, if such disclosure is required by law or if Business Associate obtains reasonable assurances from the recipient that the recipient will keep the PHI confidential, use or further disclose the PHI only as required by law or for the purpose for which it was disclosed to the recipient, and notify Business Associate of any instances of which it is aware in which the confidentiality of the PHI has been breached; (4) use PHI to provide data aggregation services relating to the health care operations of Covered Entity; (5) use or disclose PHI to report violations of the law to law enforcement; and (6) use PHI to create de-identified information consistent with the standards set forth at 45 CFR §164.514. Business Associate will not sell PHI or use or disclose PHI for purposes of marketing, as defined and proscribed in the Regulations.

B. To limit its uses and disclosures of, and requests for, PHI (a) when practical, to the information making up a Limited Data Set; and (b) in all other cases subject to the requirements of 45 CFR 164.502(b), to the minimum amount of PHI necessary to accomplish the intended purpose of the use, disclosure or request;

PAGE 2 (Business Associate Agreement)

C. To use appropriate administrative, physical and technical safeguards to protect the confidentiality, integrity and availability of the PHI in compliance with the Regulations.

D. To require all of its subcontractors and agents that receive, use or have access to PHI to agree, in writing, to adhere to the same restrictions and conditions on the use or disclosure of PHI that apply to the Business Associate pursuant to this Agreement;

E. Upon reasonable notice and prior written request, to make available during normal business hours at Business Associate’s offices all records, books, agreements, internal practices, policies and procedures relating to the use or disclosure of PHI to the Secretary, in a time and manner designated by the Secretary, for purposes of determining the Covered Entity’s compliance with the Regulations, subject to attorney-client and other applicable legal privileges;

F. To provide documentation regarding any disclosures by Business Associate that would have to be included in an accounting of disclosures to an Individual under 45 CFR 164.528 (including without limitation a disclosure permitted 74 under 45 CFR 164.512) and the HITECH Act, within a reasonable amount of time of receipt of a request from Covered Entity;

G. If, and to the extent that Business Associate possesses an applicable Designated Record Set, within a reasonable amount of time of receipt of a request from the Covered Entity for the amendment of an individual's PHI contained in the Designated Record Set, Business Associate shall provide such information to the Covered Entity for amendment and shall also incorporate any such amendments in the PHI maintained by Business Associate as required by 45 C.F.R. 164.526.

H. Subject to Section III.C.2. of this Agreement, return to the Covered Entity or destroy, within thirty (30) days of the termination of this Agreement, any and all PHI in its possession and retain no copies (which for purposes of this Agreement shall include without limitation destroying all backup tapes and permanently deleting all electronic PHI).

I. To mitigate, to the extent practicable, any harmful effects from any use or disclosure of PHI by Business Associate not permitted by this Agreement.

J. Business Associate agrees to notify the designated Privacy Official of the Covered Entity of any use or disclosure of PHI by Business Associate not permitted by this Agreement, any Security Incident involving electronic PHI, and any Breach of Unsecured Protected Health Information within five (5) business days.

1. Business Associate shall provide the following information to Covered Entity within ten (10) business days of discovery of a breach except when despite all reasonable efforts by Business Associate to obtain the information required, circumstances beyond the control of the Business Associate necessitate additional time. Under such circumstances Business Associate shall provide to Covered Entity the following information as soon as possible and without unreasonable delay, but in no event later than thirty (30) calendar days from the date of discovery of a breach: a. The date of the breach; b. The date of the discovery of the breach; c. A description of the types of unsecured PHI that were involved; d. Identification of each individual whose unsecured PHI has been, or is reasonably believed to have been, accessed, acquired, or disclosed; and PAGE 3 (Business Associate Agreement)

e. Any other details necessary to complete an assessment of the risk of harm to the individual. 2. Covered Entity will be responsible to provide notification to individuals whose unsecured PHI has been disclosed, as well as the Secretary and the media, as required by Sec. 13402 of the HITECH Act, 42 U.S.C.A. § 17932; 3. Business associate agrees to pay actual costs for notification and of any associated mitigation incurred by Covered Entity, such as credit monitoring, if Covered Entity determines that the breach is significant enough to warrant such measures. 4. Business associate agrees to establish procedures to investigate the breach, mitigate losses, and protect against any future breaches, and to provide a description of these procedures and the specific findings of the investigation to Covered Entity in the time and manner reasonably requested by Covered Entity. 5. The parties agree that this section satisfies any notices necessary by Business Associate to Covered Entity of the ongoing existence and occurrence of attempted but Unsuccessful Security Incidents (as defined below) for which no additional notice to Covered Entity shall be required. For purposes of this Agreement, “Unsuccessful Security Incidents” include activity such as pings and other broadcast attacks on Business Associate’s firewall, port scans, unsuccessful log-on attempts, denials of service and any combination of the above, so long as no such incident results in unauthorized access, use or disclosure of electronic PHI.

III. TERM AND TERMINATION:

A. Term. This Agreement shall become effective on the date of execution of a Service Agreement, and shall terminate upon the termination or expiration of all Service Agreement(s). Notwithstanding the foregoing, obligations imposed on either party pursuant to the HITECH Act must be complied with only when the particular provisions referenced become effective or compliance becomes required, whichever is later.

B. Termination for Cause. Either Party may immediately terminate this Agreement and the Service Agreement(s) if such Party makes the determination that the other Party has breached a material term of this Agreement. Alternatively, the 75 terminating Party may choose to provide the other Party with thirty (30) days written notice of the existence of an alleged material breach and an opportunity to cure the breach. If termination is not feasible, the terminating Party shall report the breach to the Secretary.

C. Effect of Termination.

1. Upon termination or expiration of this Agreement, Business Associate agrees to return to Covered Entity or destroy all PHI in the possession of Business Associate and/or in the possession of any subcontractor or agent of Business Associate (including without limitation destroying all backup tapes and permanently deleting all electronic PHI) and to retain no copies of the PHI.

PAGE 4 (Business Associate Agreement)

2. In the event that returning or destroying the PHI is infeasible, Business Associate shall provide to Covered Entity a written statement that it is infeasible to return or destroy the PHI and describe the conditions that make return or destruction of the PHI infeasible. Upon mutual agreement by the Parties that return or destruction of the PHI is infeasible; Business Associate shall extend the protections of this Agreement to such PHI and limit further uses and disclosures of such PHI to those purposes that make the return or destruction infeasible, for so long as Business Associate maintains the PHI.

IV. INDEMNIFICATION:

Business Associate agrees to indemnify, defend and hold harmless Covered Entity and its respective employees, directors, officers, subcontractors, agents or other members of its workforce (each of the foregoing hereinafter referred to as “Indemnified Party”) against all actual and direct losses suffered by the Indemnified Party and all liability to third parties arising from or in connection with any breach of this Agreement or from any acts or omissions related to this Agreement by Business Associate or its employees, directors, officers, subcontractors, agents or other members of its workforce. Accordingly, on demand, Business Associate shall reimburse any Indemnified Party for any and all actual and direct losses, liabilities, lost profits, fines, penalties, costs or expenses (including reasonable attorneys’ fees) which may for any reason be imposed upon any Indemnified Party by reason of any suit, claim, action, proceeding or demand by any third party which results from the Business Associate’s acts or omissions hereunder. Business Associates’ obligation to indemnify any Indemnified Party shall survive the expiration or termination of this Agreement.

V. MISCELLANEOUS:

A. Amendments. This Agreement may not be modified, nor shall any provision hereof be waived or amended, except in a writing duly signed by authorized representatives of the Parties. The parties agree to take such action as is necessary to amend this Agreement from time to time as is necessary to achieve and maintain compliance with the requirements of the Regulations.

B. Survival. The respective rights and obligations of Business Associate and Covered Entity set forth in Sections III.C. and IV shall survive termination of this Agreement.

C. Regulatory References. Any reference herein to a federal regulatory section within the Code of Federal Regulations shall be a reference to such section as it may be subsequently updated, amended or modified.

D. Interpretation. Any ambiguity in this Agreement shall be resolved to permit covered entities to comply with HIPAA.

E. Notices. Any notices given hereunder shall be in writing and addressed as follows:

If to Covered Entity

[NAME] [ADDRESS] [Attention]

76 If to Business Associate

______Attention: ______

IN WITNESS WHEREOF, each of the undersigned has caused this Agreement to be executed by its duly authorized representative.

FOR ______[insert name of covered entity here]

By: ______Date Name: ______Title: ______

Reviewed By:

______, Privacy Official [Input HIPAA compliance officer’s name here]

FOR BUSINESS ASSOCIATE

______Date Name: ______Title: ______

77

Informed Consent To Chiropractic Treatment

The nature of chiropractic treatment: The doctor will use his/her hands or a mechanical device in order to move your . You may feel a “click” or “pop," such as the noise when a knuckle is “cracked”, and you may feel movement of the joint. Various ancillary procedures, such as hot or cold packs, electric muscle stimulation, therapeutic ultrasound or traction may also be used.

Possible risks: As with any health care procedure, complications are possible following a chiropractic manipulation. Complications could include fractures of bone, muscular strain, ligamentous sprain, dislocations of joints, or injury to intervertebral discs, nerves or . Cerebrovascular injury, or stroke, could occur upon severe injury to arteries of the neck. A minority of patients may notice stiffness or soreness after the first few days of treatment. The ancillary procedures could produce skin irritation, burns or other minor complications.

Probability of risks occurring: The risks of complications due to chiropractic treatment have been described as “rare”, about as often as complications are seen from the taking of a single tablet. The risk of cerebrovascular injury, or stroke, has been estimated at one in one million to one in ten million, and can be even further reduced by screening procedures. The probability of adverse reaction due to ancillary procedures is also considered “rare”.

Other treatment options that could be considered may include the following:  Over-the-counter . The risks of these include irritation to stomach, liver and kidneys, and other side effects in a significant number of cases.  Medical care, typically anti-inflammatory drugs, tranquilizers, and analgesics. Risks of these drugs include a multitude of undesirable side effects and patient dependence in a significant number of cases.  Hospitalization in conjunction with medical care adds risk of exposure to virulent communicable disease in a significant number of cases.  Surgery in conjunction with medical care adds the risks of adverse reaction to anesthesia, as well as an extended convalescent period in a significant number of cases.

Risks of remaining untreated: Delay of treatment allows formation of adhesions, scar tissue and other degenerative changes. These changes can further reduce skeletal mobility, and induce chronic pain cycles. It is quite probable that delay of treatment will complicate the condition, and make future rehabilitation more difficult.

Unusual risks: I have had the following unusual risks of my case explained to me:

I have read the explanation above of chiropractic treatment. I have had the opportunity to have any questions answered to my satisfaction. I have fully evaluated the risks and benefits of undergoing treatment. I have freely decided to undergo the recommended treatment, and hereby give my full consent to treatment.

______

Printed name Signature Date

78 Forms CD Table of Contents (from text book appendix) NOTE: The bold/highlighted forms are routinely used in my office.

A CHAPTER 5: GENERAL HEALTH QUESTIONNAIRES...... 493 A-1. Health Status Questionnaire (HSQ-36): Decoded Version/493 A-2. Health Status Questionnaire (HSQ-36)/497 A-3. SF-36 Health Status Summary/500 A-4. Health Status Questionnaire (HSQ-12): Decoded Version/501 A-5. Health Status Questionnaire (HSQ-12)/504 A-6. SF-12 Health Status Summary/506 A-7. Dartmouth Coop Charts/507 A-8. Dartmouth Coop General Health Questionnaire Summary of Results/510

B CHAPTER 6: ASSESSMENT OF PAIN...... 511 B-1. Quadruple Visual Analogue Scale/511 B-2. Pain Related Questionnaire/512 B-3. Short-Form McGill Pain Questionnaire/513

C CHAPTER 7: CONDITION-SPECIFIC OUTCOME ASSESSMENT TOOLS ………..514 C-1. Low Back Pain and Disability Questionnaire/514 C-2. Revised Oswestry Low Back Pain Disability Questionnaire/515 C-3. The Quebec Back Pain Disability Scale/517 C-4. North American Spine Society Low Back Pain Outcome Instrument (NASS)/518 C-5a. Sample Curtin Back Screening Questionnaire/529 C-5b. Curtin Back Screening Questionnaire/530 C-6. Activities Discomfort Scale/531 C-7. Low Back Outcome Scale: Scoring Template/532 C-8. Clinical Back Pain Questionnaire/533 C-9. Spinal Stenosis Treatment Outcome Questionnaire/535 C-10. Neck Disability Index Questionnaire (NDI)/537 C-11. Headache Disability Index/539 C-12. Dizziness Handicap Inventory/540 C-13. Tinnitus Handicap Inventory/541 C-14. Hearing Handicap Inventory for Adults/542 C-15a. TMD Disability Index C-15b. TMD Symptom Intensity Scale (SIS) and Symptom Frequency Scale (SFS)/545 C-15c. Scoring Method for the TMD Disability Index/546 C-16. Carpal Tunnel Syndrome Questionnaire (CTSQ)/547 C-17a. Shoulder Evaluation Form (American Shoulder and Elbow Surgeons)/548 C-17b. Shoulder Injury Self-Assessment of Function/549 C-18. Rating Scale of the American Shoulder and Elbow Surgeons/550 C-19. Simple Shoulder Test Questionnaire/551 C-20. University of California at Los Angeles Shoulder Rating Scale/552 C-21. Patellofemoral Function Scale/553 C-22. Subjective Knee Score Questionnaire/554 C-23. Rating of Knee Replacement Results/556 C-24. Rating of Hip Replacement Results/558 C-25. Beck Depression Inventory/560 C-26. Modified Somatic Perception Questionnaire/561 C-27. Modified Zung Depression Index/562

D CHAPTER 9: PATIENT SATISFACTION AND EXPERIENCE...... 563 D-1. Example of a Client Experience Survey/563 D-2. The Chiropractic Satisfaction Questionaire/564

E CHAPTER 14: SPINAL RANGE OF MOTION...... 565 E-1. McKenzie Examination Form/565

F. CHAPTER 15: OUTCOME MEASURES FOR THE UPPER AND LOWER EXTREMITIES … 567 F-1. Constant Scale/567 79 F-2. Hospital for Special Surgery Score Sheet for Total Shoulder Replacement/568 F-3. Shoulder Function Assessment Scale/569 F-4. Croft’s Measurement of Shoulder-related Disability/567 F-5. Wolfgang’s Assessment of Rotator Cuff Injury/571 F-6. Shoulder Pain and Disability Index (SPADI)/572 F-7. Shoulder Rating Questionnaire (SRQ)/573 F-8. Athletic Shoulder Outcome Rating Scale/576 F-9. University of Washington Shoulder Information Form/578 F-10. Preoperative and postoperative Scores Obtained Using the 12-Item Shoulder Questionnaire/579 F-11. Mayo Elbow Performance Index/581 F-12. Elbow Functional Rating Index/582 F-13. Patient-rated Wrist Evaluation/583 F-14. Functional Disability Index for the Rheumatoid Hand/585 F-15. Patient-specific Index (Hip)/586 F-16. Hip-Rating Questionnaire/588 F-17. Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index/590 F-18. Index of Severity for Hip Osteoarthritis/593 F-19. International Knee Documentation Committee Assessment Form/594 F-20. American Knee Society’s Assessment System/596 F-21. Anterior Knee Pain Questionnaire/598 F-22. Harrison’s Patellofemoral Pain Syndrome Scale/600 F-23. Index of Severity for Knee Osteoarthritis/601 F-24. Scoring system of Subjective Clinical Evaluation (Ankle)/602 F-25. Olerud and Molander Scoring System (Ankle)/603 F-26. Ankle Clinical Scoring System/604 F-27. Ankle Grading System/606 F-28. A Performance Test Protocol and Scoring Scale for the Evaluation of Ankle Injuries/608

G CHAPTER 16: MEASURING PHYSICAL PERFORMANCE...609 G-1. Health-related Fitness Test Battery for Adults/609 G-2. Prone Press-up Examination Form/610 G-3. NIOSH Distinguishing LBP Tests/611 G-4. Sacroiliac Examination Form/612 G-5. Visual Analogue Scale (VAS)/613 G-6. Quantitative Functional Capacity Evaluation/614 G-7. Quantitative Functional Capacity Results/618 G-8. Qualitative Functional Tests/620 G-9. Posture, Gait and Movement Pattern Assessment/634 G-10. Static Position Tolerance Tests/636

H CHAPTER 19: CASE MANAGEMENT IN AN EVIDENCE-BASED PRACTICE...... 683 H-1. CareTrak Checklist: Low Back Classification/638 H-2. Red Flags Checklist (AHCPR)/640 H-3. CareTrak Checklist: Cervical Classification/642 H-4. Outcomes Assessment Record/644 H-5. Job Demands Questionnaire/646 H-6. Assessment and Treatment Plan/648 H-7. Modified Work APGAR/651 H-8 Vermont Disability Prediction Questionnaire/652

I CHAPTER 21: IDENTIFICATION OF THE PATIENT AT RISK FOR LOW BACK TROUBLE...654 I-1. Risk Factor Assessment: Standard Questionnaire/654 I-2. Risk Factor Assessment: Re-examination Questionnaire/656 I-3. Scoring/657

J CHAPTER 22: PUTTING OUTCOMES-BASED MANAGEMENT INTO PRACTICE …………. 660 J-1. Physical Therapy Log/660 J-2. Nutrition/Medication/Brace-Orthotic log/662 J-3. Photocopy Log/663 J-4. Daily SOAP Notes/664 J-4a. Abbreviation Key for SOAP Notes/666 80 J-5a. Consultation/History/667 J-5b. Past history/668 J-5c. Review of Systems (ROS)/669 J-5d. Cervical Spine and Lumbar Spine Examination Forms/670 J-6. Sample X-ray Report/674 J-7. Attending Physician’s Return to Work Recommendations/675 J-8. Route Slip/676

NEW FORMS DISC (Outcome measures published since 2000 – not included in the textbook)

TABLE OF CONTENTS (Bundled with the Forms CD) SUBJECTIVE OUTCOME TOOLS

OA Tool Author / Reference 1. Back Pain Functional Scales Stratford / Spine, 2000 2. Cervical Spine – Bournemouth Questionnaire Bolton, Humphreys / JMPT, 2002 3. Low Back – Bournemouth Questionnaire Bolton, Breen, JMPT, 1999 4. Copenhagen Neck Functional Disability Scale Jordan / JMPT, 1998 5. Dallas Pain Questionnaire (in French) Lawlis / Spine, 1989 6. Shoulder Pain Disability Index – SPADI Roach / Arthritis Care Res, 1991 7. Functional Rating Index (FRI) Feise / Spine, 2001 8. Functional Assessment Screen Q (FASQ) Millard / Arch Phys Med Rehabil., 1989 9. Fear-Avoidance Beliefs Q (FABQ) Waddell / Pain, 1993 10. Symptom Check List 90-R (SCL-90-R) Derogatic LR / Administration, Scoring and Procedures Manual-I & II, 1983 11. Rehab SOAP note* Yeomans / Rehab Course notes, 1995-2005 12. Functional Assessment Scale (Knee) Wegener L, Kisner C, Nichols D. Static and dynamic balance responses in persons with bilateral knee osteoarthritis. JOSPT 1997;25:13 13. Upper Extremity Function Scale Questionnaire Pransky G, Feuerstein M, Himmelstein J, Katz JN, Vickers-Lahti M. / JOEM, 1997 14. Spanish Q’s Oswestry, RM-24, NDI, SF-36 15. Informed Consent form NA * The Rehab SOAP note (#11) is not a peer-reviewed outcomes assessment form but rather, an optional documentation approach when administering rehabilitation services.

OBJECTIVE OUTCOME TOOLS

1. Cervical Spine QFCE Yeomans / CMCC 10/2001 lecture 2. Cervical Non-organic signs (see 1 for form) Sobel / Arch Phys Med Rehabil 2000 Sports Screen 3. Sports Screen Yeomans / Research tool (not yet published) Pre-Employment Exam 4. Pre-employment Exam* Yeomans / Research tool (not yet published) * It is highly recommended that the Spinal Function Sort be included with this examination.

NOTE: This material is packaged with the “Forms CD” which contains all the outcomes assessment tools and documentation forms found in the text, The Clinical Application of Outcomes Assessment. Ed. SG Yeomans, Appleton & Lange, 2000.

For software scoring capabilities: visit www.caretrak-outcomes.com and other outcomes assessment distance-learning approaches visit www.yeomansdc.com or see the following description of materials: Recommended Publications:

81 1) The Chiropractic Report Subscription $110 (reg. price)

1989 (Volume 3) 1995 (Volume 9) No 1 International Congress (Sydney) No 1 Chiropractic Research in the Centennial Year No 2 Immobilization - New evidence No 2 Authoritative New Guidelines for Management of Back Pain: US and UK Guides No 3 Spinal Adjustment - Principles & Results No 3 Primary Headaches & Cervical Spine Dysfunction * No 4 Disc Problems No 4 Redefining Whiplash and its Management * No 5 The Future of Chiropractic No 5 The powerful and Mysterious Placebo * No 6 The Chiropractor as an Expert Witness * No 6 Chiropractic Management of Visceral Disorders 1990 (Volume 4) 1996 (Volume 10) No 1 Infantile Colic No 1 Representing chiropractic in 1996 * No 2 Chronic Low Back Pain No 2 Managed Care - The Right Attitude No 3 Sacroiliac Dysfunction No 3 The Chiropractic World No 4 Sports Chiropractic No 4 Rehabilitation and Chiropractic Pracitce * No 5 British MRC Trial * No 5 RAND Report on Cervical Manipulation No 6 Medical Texts with Chiropractic Principles No 6 Chronic Pain after Whiplash * 1991 (volume 5) 1997 (Volume 11) No 1 Medical Referrals * No 1 Managing Patients with Low-Back Pain: Summary of Recent Guidelines * No 2 Chiropractic Management of Headache No 2 The Chiropractic Profession * No 3 Practice Guidelines No 3 The Spine and the Nervous System: New Knowledge of somatovisceral Reflexes * No 4 1991 World Chiropractic Congress No 4 Lessons from the Marketplace * No 5 Vertigo No 5 The Role of subluxation in Chiropractic * No 6 The RAND Study No 6 Exercise Programs - Do they Really Work * 1992 (Volume 6) 1998 (Volume 12) No 1 Stress and Exercise No 1 Depression in Chronic Pain Patients No 2 Referral Letters and Written Reports* No 2 Cost-effectiveness – The Second Manga Report No 3 North American Practice Guidelines No 3 Cervicogenic Headache – New Anatomical Discovery Provides the Missing Link No 4 Manipulation for Chronic Back Pain No 4 Low-Force & Soft-tissue Techniques No 5 Children and Infants No 5 Chiropractic History: The Evolution to Acceptance No 6 WFC-World Review and Japan No 6 Back Pain, Science, Politics and Money 1993 (Volume 7) 1999 (Volume 13) No 1 Measuring Results: Patient Questionnaires No 1 Exercise & Health – New Guides for the Clinician No 2 The Sacroiliac Joints Re-visited No 2 Complimentary & Alternative Medicine No 3 The Chiropractic Profession No 3 The Future of Chiropractic No 4 Lumbar Disc Herniation No 4 Cervical Adjustment No 5 1993 World Chiropractic Congress No 5 Key Journals, New Books & Knowledge No 6 Cost Effectiveness: The Manga Report No 6 Infantile Colic No 7 Independence Strengths / Limitations 1994 (Volume 8) 2000 (Volume 14) No 1 Long-term Care - Justification No 1 Chronic Back and Neck Pain No 2 Biomechanical Basis for Whiplash* No 2 Non-Musculoskeletal Benefits of Chiropractic Care No 3 Cervical Spine and Vertebral Artery Injury* No 3 Integration - Its Importance and Its Challenges No 4 Chiropractic Education & Licensure * No 4 Measuring Results with Patient Questionnaires No 5 Orthopractic - Politics or Science No 5 Back Pain Guidelines from Denmark No 6 Chiropractic Research in the Centennial Year No 6 Chiropractic in Court Subscription and order form 6 bi-monthly issues - year commences in January

Name: ______Address: ______Telephone: ______Check  VISA  MasterCard  Card #: ______Expiration Date: ______Send order and payment to: The Chiropractic Report (CR:StYE) 203-1246 Yonge Street Toronto, Ontario, Canada M4T 1WS Telephone: (416) 484-9601 Fax: (416) 484-9601 E-mail: [email protected] WEBSITE: www.chiropracticreport.com

82

(Others recommended publications)

2) Soft-Tissue Review: Body-Mind Publications, PO Box 465, Olympia WA 98507-0465; 800-715-5289 3) Spinal Manipulation: FCER, 703-276-7445 4) Topics in Clinical Chiropractic: Aspen Publishing 800-234-1660 5) Journal of Rehabilitation Outcomes Measurement: Aspen Publishing 800-234-1660 6) Journal of Manipulative and Physiological Therapeutics (JMPT): Williams & Wilkins, 800-633-6423 7) Spine: JB Lippincott Co., PO Box 1600, Hagerstown, MD 21741-1600* 8) Text: Rehabilitation of the Spine: A practitioner's Manual, ed. Craig Liebenson, Williams & Wilkins, 1996 800-358-3583

* I HIGHLY RECOMMEND ORDERING A REPRINT OF THE 2-15-08S ISSUE ON NECK PAIN:

Neck Pain and the Decade of the Bone and Joint 2000-2010 Spine:Volume 33(4S) Supplement15 February 2008

RECOMMENDED TOOLS

Software:

83

CareTrak Outcomes Software

SPECIAL OFFER

CareTrak Outcomes Software helps you generate outcomes reports for documenting your patient’s progress under your care. The software utilizes the most scientifically validated questionnaires. All of these are clinically tested and simple for patients to fill out.  OSWESTRY  ROLAND-MORRIS  NECK DISABILITY INDEX  VISUAL ANALOG SCALE

The CareTrak Software Automatically Generates Outcome Reports That Can Help Your Practice in the Following Ways:  Excellent communication with referring physicians  Chart documentation  Med-legal documentation

The Benefits of CareTrak’s Outcomes Software Include:  Takes less than 5 minutes for you or your staff to input for a 1st visit  Takes less than 2 minutes for follow-ups  Excellent marketing tool for generating physician referrals  Excellent documentation of patient progress for med-legal reports, depositions, testimony, and insurance appeal

Other Components of the Software Include:  Functional capacity evaluation  Diagnostic triage  Risk factor identification  Posture/gait/movement pattern analysis  Automatic report generation with rehabilitation prescription  SF-36 Health Status Questionnaire  Patient Satisfaction questionnaires (3 choices)  ….and more!

**** Try a DEMO at www.caretrak-outcomes.com ****

84 Text Overview: The Clinical Application of Outcomes Assessment, Ed. S.G. Yeomans, DC, FACO

Today’s professional faces a great challenge to balance the many aspects of what is considered appropriate care. The clinician must provide care that enhances the patient’s self-reliance, while we as health care providers are expected to maintain quality in a cost-conscious way. This not only opens the door but also makes imperative the need for evidence-based practice to become a reality. Traditionally, health care providers have relied upon assumption-based science which provides so called “objective" indicators of physiology and function, only to learn that many of these tests and examination findings have limited value, are not reproducible, and at times even fail to accomplish what we expect. Our understanding is further complicated by new, more expensive medical technologies that are evolving at breakneck speed, based on either intuitive thinking or assumptions that require great leaps of faith to be applicable to our patients. This text offers a didactic description and literature review of many outcome tools as well as the classic examination approach. On the practical side, an appendix is included that contains many subjective and objective tools that can be copied and utilized by providers of all disciplines that emphasizes conditions involving the neuromusculoskeletal system.

The Clinical Application of Outcomes Assessment was inspired after realizing the painstaking experience of trying to locate various evidence-based tools that could be utilized to track care over time in a clinical setting. Therefore, the mission of writing this text was to create one resource where health care providers can go to find outcome tools, and determine the how, when, and where to implement an outcome tool in practice. The concept of practicing in an evidence based, outcomes managed (OM) environment is the heart of this project. This is what is becoming expected of all of us that provide patient care.

The text is divided into 4 sections that cover the basic concepts of OM. These include:

 Outcomes Assessment Overview  Subjective OA Tools  Objective OA Tools  Application of OA into Clinical Practice  Practical reality: Commonly asked questions regarding OA’s ______

Since the release of the text, I have continued to produce distance learning tools that include a CD of forms of both the text’s appendix as well as new tools released after the year the text was released (2000), a DVD and manual of the QFCE and a CD and manual of exercise protocols specific to each of the physical performance tests. These tools allow for immediate implementation of methods that will help you establish an evidence- based documentation and practice approach.

Please contact me and visit my website, www.yeomansdc.com to obtain a list of materials available. You can also email or fax my office for an updated list as well ([email protected] or fax at 920-748-3642). If you have any questions feel free to contact me at 920-748-3644.

Steven G. Yeomans, DC, FACO 404 Eureka St. Ripon, WI 54971-0263

85 CLINICAL APPLICATION OF OUTCOMES ASSESSMENT ed. Steven G. Yeomans, DC, FACO TABLE OF CONTENTS

INTRODUCTION FORWARD: Stanley Bigos

SECTION I Outcomes Assessment Overview CHAPTER 1 Why Outcomes? Why Now? (Dan Hansen, B. Mootz, S. Mior) CHAPTER 2 Attributes to Look for in Outcome Measures (H Vernon, C Hagino) CHAPTER 3 Subjective versus Objective, Qualitative versus Quantitative, and Provocative Testing: What does it all mean? (SY) CHAPTER 4 Classification of Outcomes Assessment instruments (SY)

SECTION II Subjective OA Tools (These chapters will include an appendix of tools) CHAPTER 5 General Health Questionnaires (SY) CHAPTER 6 Assessment of Pain (SY) CHAPTER 7 Condition-specific Outcome Assessment Tools (SY) CHAPTER 8 Measuring Psychosocial Outcomes in Clinical Practice (David Williams, MD /Michael Feuerstein, MD) CHAPTER 9 Patient Satisfaction and Experience (Tom Zastowney, Ph.D) CHAPTER 10 Predicting Outcome in Low Back Pain (Jeff Fitzthum, DC, MD)

SECTION III Objective OA Tools CHAPTER 11 High-tech verses Low-technology (David Stude, DC, Gunnar Andersson, MD) CHAPTER 12 Strength and Endurance Testing (Hennu Alaranta, MD, Ph.D.) CHAPTER 13 Spinal Orthopedic and Neurological Testing (SY) CHAPTER 14 Spinal Range of Motion: Is This a Valid Form of Outcomes Assessment? (SY) CHAPTER 15 Outcome measures for the Upper and Lower Extremities (Jeffery Wilder) CHAPTER 16 Measuring Physical Performance (SY) CHAPTER 17 Functional Capacity Assessments and Low Back Pain (Bruce Hoffman, DC) CHAPTER 18 Cardiovascular Fitness Testing (William Defoyd, DC)

SECTION IV Application of OA to Clinical Practice CHAPTER 19 Case Management in an Evidence-based Practice (SY) CHAPTER 20 Integrating Outcomes Assessment into Clinical Documentation and Establishing an ”Outcomes Based Practice” (Jeffery Wilder, DC) CHAPTER 21 Identification of the Patient at Risk for Persistent or Recurrent Low Back Trouble (Craig Liebenson/SY) SECTION V Practical reality: Commonly Asked Questions regarding Outcomes Assessment CHAPTER 22 Putting Outcomes-based Management Into Practice CHAPTER 23 Clinical Outcome Data Bases - Ed E. Dobrzykowski, PT, MHS CHAPTER 24 Positioning for the future: Using Outcomes Management To Enhance Customer Service (Robert D. Mootz, Daniel T. Hansen, Silvano Mior)

If Paying By Credit Card, Fax Order Form To: 920-748-3642 (If questions, call 920-748-3644): If Paying By Check, Send Check and Order Form To Address below (see order form)

86 DESCRIPTION OF ITEMS AVAILABLE FOR PURCHASE PACKAGE 1: DOCUMENTATION PACKAGE

1. Forms & New Forms CD: This CD contains the outcome assessment forms included in the text appendix, “The Clinical Application of Outcomes Assessment”, pp493-676 AND new forms released since the release of the text in the year of 2000. The text forms include documentation options, questionnaires, and outcomes management tools. Over 2000 hours of time was utilized in producing these forms/ questionnaires. Using the CD allows you to "personalize" or modify the forms as desired such as inserting your name. The Disc is compatible for Windows 95 and newer. The New forms includes 12 subjective outcomes tools and 4 objective tools, including a cervical spine specific QFCE, a sports screen QFCE, and a pre-employment QFCE. Permission has been granted to use these forms in your office! 2. Disc of Macros: Contains MANY macros/boiler plates used for dictation, including a data file for Dragon Dictate! 3. Text Book PDF: The Clinical Application of Outcomes Assessment, Ed. SG Yeomans, Appleton & Lange, 2000. This is an electronic/PDF version of the 696 text book, which includes 183 pages of forms located in the Appendix that correlate with #1 (above). The background, statistical data, and scoring methods are covered in the text’s chapters. 4. Sample Forms for Documentation: Included are subjective, objective, plus other forms organized in an easy to follow format. These forms (and many more) are available on CD (#1 above). This is a set of forms that are utilized in the documentation class in electronic format for clean printing and personalizing with your logo if desired. PACKAGE 2: FUNCTIONAL TESTING & EXERCISE PACKAGE

1. QFCE Manual: The QFCE manual is “a must” when performing the QFCE exam. It includes both a verbal description of each test, a picture of the test for quick reference, a normative data chart & references. 2. VHS Video: This is a "live" version of the QFCE exam. This serves both as a training tool for yourself &/or staff and as a periodic update trainer as needed with personnel changes as staff turnover occurs quite frequently. 3. CD & Exercise Manual: This is a collection of exercise hand-outs/prescriptions designed to help you during rehab of the patient that follow the QFCE protocol. The files containing the exercises are divided into folders tabulated by each QFCE test number for easy identification. Modifications can be made if desired by using the CD and blank template to create your own specific prescriptions. 4. Inclinometers: Two inclinometers are required to measure spinal range of motion and one is needed for the muscle length tests. This is a hardware store version (cheap) that work great! These have a pointer for marking your starting point, which is unique as many hardware stores brands do NOT have that feature. 5. Straps: Seatbelts used in securing patients to the table during QFCE testing (eg., Static Back Endurance test).

* ADD ONS – DISTANCE LEARNING MATERIALS * 1. An Overview of Clinical Documentation: Included are the ACA and WCA recommendations for documentation, a chart audit, a list of "Yellow Flags" to communicate barriers to recovery, a list of commonly used CPT Codes and a bibliography. 2. Clinical Documentation for PI Cases: Includes forms in regards to Accident History, Expanded History, etc. This will assist you in preparing for depositions, trial and report writing. An article entitled; Whiplash: Cervical Musculoligamentous Injuries is included as well as accident reconstruction information. 3. WC Documentation: This includes additional outcomes assessment forms including work satisfaction tools, Job Demands questionnaires and Pre-Placement Examinations. 4. Chronic Pain Syndrome: These notes include evidence-based practice strategies, OA tools, objective tools - including the cervical and LB non-organic signs, research abstracts (including CNS sensitization), whiplash, spinal stenosis, and other topics. 5. Outcomes Assessment – An Evidence Based Practice Approach: This includes the 3 necessary steps to become “evidence-based”, what OA Tools are available, when to apply them, and a description of the subjective and objective outcomes tools. Examples of Assessment, Plan, and Patient Profiling/Yellow flags is included. 6. Spinal Function Sort: EXAMINER’S MANUAL (40 pages) AND PATIENT CHARTS (28 pages) – This allows for an evidence-based method of returning a patient to work where the patient’s perception of disability is quantified using 50 pictured items of activities of daily living commonly performed. This coupled with static position tolerance tests, Job Demands Questionnaire, and the QFCE facilitates determining functional capacities when returning patient to work.

87 7. Hand Function Sort: EXAMINER’S MANUAL (32 pages) AND PATIENT CHARTS (36 pages) This is essentially the same thing as The Spinal Function Sort (#6) but its specific for hand/upper extremity function. 8. Impairment Rating: 4th, 5th & 6th Edition class notes: Please note, the text, “The AMA Guides to the Evaluation of Permanent Impairment” is needed to actually perform an impairment rating. These notes are a great supplement and include forms needed in the evaluation process. 9. Clinical Application of Outcomes in the Management of Neck Pain. Subjective and objective outcomes tools utilized in the management of patients with neck pain are reviewed in these notes. New QFCE-C-spine tests are included (Ravel's laser light test, Louden's CROM proprio test, Jull's strength test, the C-non-organic signs, and more). 10. CTS article review: This is a compilation of articles including a chiropractic case management approach – excellent for sharing with insurers. The articles are categorized by outcome, diagnosis, epidemiology, and side effects. A CTS study SGY was involved in is included. 11. Pre-employment / Post-hire exam: A CD includes subjective and objective components needed when performing pre- employment/post-hire examinations. 12. Whiplash CD: This includes a PowerPoint Slide show re: the mechanism of injury and, many articles & forms for WAD. 13. Text Book: The Clinical Application of Outcomes Assessment, Ed. SG Yeomans, Appleton & Lange, 2000. This is an version of the 696 text book, which includes 183 pages of forms located in the Appendix that correlate with #1 (above). The background, statistical data, and scoring methods are covered in the text’s chapters. ITEM EACH QUANTITY TOTAL

1 Overview of Clinical Doc. $20

2 Clinical Documentation for PI Cases $40

3 WC Documentation $20

4 Chronic Pain Syndrome $40

5 Outcomes Assessment – An Evidence Based Practice $40 Approach

6 Spinal Function Sort $50

7 Hand Function Sort $50

8 Impairment Rating: 4th, 5th & 6th Edition class notes $50

9 Clinical Application of Outcomes in the Management of Neck $30 Pain

10 CTS article review $50

11 Pre-employment / Post-hire exam $50

12 Whiplash CD $100

13 Text Book: The Clinical Application of Outcomes Assessment $70 (note: PDF = $50)

14 Inclinometer (Hardware Store variety) $20

Tax WI Residence 5.5% $

Shipping/Hand $10 (Out of Country $25) $ TOTAL $

88 SEE LAST PAGE FOR SPECIAL PACKAGES Software for Exercises (QFCE Specific): 1) Phases Rehab Exercise Software & QFCE & Exercise CD option

a. Phases Rehab 2005 (V. 3.1.0, 8/2005 ) CD: ……………………. $399

b. Phases Rehab QFCE Protocol CD ROM ( 8/2005) ……………… $89.99

i. Includes a FREE update to Phases V.3.1.0 for prior owners

d. Extremity Protocols (based on diagnoses)………………………….. $50

e. SPECIAL: BOTH (399+89.99+50 = $538.99 ): ……………. $379 2) WebExercises - Select from over 1,000 clinically-accepted exercises and stretches for all parts of the body and build your own exercise forms. Instruction sheets can be printed or delivered by email, customized with your clinic's name and logo. Dr. Yeomans created a companion CD to the WebExercises Desktop. This CD-ROM includes 73 exercise templates for the Quantitative Functional Capacity Evaluation and for Extremity Exercises as well. The CD is easily loaded onto a hard drive. This should be done after the WebExercises disc has already been installed. The WebExercises QFCE Templates will then appear on the template page on WebExercises. The WebExercises QFCE Templates is ideal to assist chiropractors in designing effective evidence-based exercise prescriptions for their patients with a body wide spectrum of musculoskeletal disorders. (For both CDs)… $379

3) Nexerciser – a muscle strength assessment and rehab tool that allows for a determining isometric maximum voluntary contraction (MVC) of the cervical spine and extremities. It also functions as a biofeedback device during rehab as a percentage of the MVC can be targeted as well as a gradual crescendo/ decrescendo (ramp up / down) can be utilized to restore neuromotor control ……………………... …….……………. $215

FREE Outcomes Assessment articles are available online at www.yeocmansdc.com

89 SPECIAL PACKAGES Reg. Price Seminar Special Package 1 $290 (20% Seminar special) $230 Package 2 $315 (20% Seminar special) $255 Package 1 & 2 $605 (30% Seminar special) $425

Package Cost* Content

Forms/New Forms CD, Dictation Macros, PDF/Textbook (Clinical Package 1 $230 Application of Outcomes Assessment, ed. SG Yeomans), Sample Forms Documentation for Documentation

QFCE Manual & DVD, Exercise Manual & CD, Extremity Exercise Package 2 $255 Screen and Exercise Manual, 2 Inclinometers, and a 9’ strap Functional Testing & Exercise

NOTE: 30% off vs. 20% BOTH 1 & 2 $425 “ADD ON’s”

Includes: Phases ($399) + QFCE Protocols ($90) + Extremities ($50) = PHASES or $379 $539 regular price / now, $439. See page 3 for more information. WebEx. Pkg PACKAGE NUMBER: ______NOTE: WI Residents add 5.5% Tax TOTAL: ______

Make Checks out to: “PES” (Professional Educational Services, LLC); NOTE: Please insert the address where the Credit Card bill is sent (i.e., do NOT insert an office address with a personal Credit Card # or vice versa). If the shipping address is different, please write it on the back of the form. Name______Address______City______State:______Zip______

Phone # ______Fax # ______E-Mail______Credit Card: # ______Exp______Card Verif # ______DON’T FORGET THE 3 DIGIT NUMBER ON THE BACK OF THE CARD ] If Paying By Credit Card, Fax Order Form To: 920-748-3642 (If questions, call 920-748-3644 or email: [email protected]): If Paying By Check, Send Check and Order Form To: Dr. SG Yeomans, 404 Eureka St., Ripon, WI 54971-0263.

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