BACK Appearance* Normal Swelling Redness Erythema Deformity Scars OtherPalpation* 1. Top Right 2. Top Left 3. Mid Right 4. Mid Left 5. Low Right 6. Low Left 7. Other Observed Abnormality? Yes No Sensation Intact? Yes No Moves Extremities w/o Deficit? Yes No Strength 1 2 3 4 5 Deep Tendon Reflexes 0 1 2 3 4 Range Of MotionFlexion Full Limited LevelPainPlease enter a number from 0 to 10.ExplainExtension Full Limited LevelPainPlease enter a number from 0 to 10.ExplainSidebending Right Full Limited LevelPainPlease enter a number from 0 to 10.ExplainSidebending Left Full Limited LevelPainPlease enter a number from 0 to 10.ExplainRotation Full Limited LevelPainPlease enter a number from 0 to 10.ExplainProcedure Note Consent Skin Cleaned with Chlohexadine Other Tender Points Injected with: Dextrose PRP Joint Injection: Dextrose PRP Stem Cell Resolution of Symptoms? Yes No Tolerated Well? Yes No Proceedural Sedation:Medication 1AtivanDilaudidDemerolFentanylKetamineMorphineValiumVerscelDose Medication 2AtivanDilaudidDemerolFentanylKetamineMorphineValiumVerscelDose Medication 3AtivanDilaudidDemerolFentanylKetamineMorphineValiumVerscelDose Δ
