LOW BACKAppearance* Normal Swelling Redness Erythema Deformity ScarsOtherPalpation* R1 R2 R3 R4 R5 L1 L2 L3 L4 L5 1. Iliolumbar Ligament Right 2. Iliolumbar Ligament Left 3. SI Right 4. SI Left 5. Right Ilium 6. Left Ilium 7. Right Lateral Sacral Border 8. Left Lateral Sacral Border 9. OtherObserved Abnormality? Yes NoSensation Intact? Yes NoMoves Extremities w/o Deficit? Yes NoStrength 1 2 3 4 5Deep Tendon Reflexes 0 1 2 3 4Range of MotionFlexion Full LimitedLevelPainPlease enter a number from 0 to 10.ExplainExtension Full LimitedLevelPainPlease enter a number from 0 to 10.ExplainSidebending Right Full LimitedLevelPainPlease enter a number from 0 to 10.ExplainSidebending Left Full LimitedLevelPainPlease enter a number from 0 to 10.ExplainRotation Full LimitedLevelPainPlease enter a number from 0 to 10.ExplainProcedure Note Consent Skin Cleaned with Chlohexadine OtherTender Points Injected with: Dextrose PRPResolution of Symptoms? Yes NoTolerated Well? Yes NoProceedural Sedation:Medication 1AtivanDilaudidDemerolFentanylKetamineMorphineValiumVerscelDoseMedication 2AtivanDilaudidDemerolFentanylKetamineMorphineValiumVerscelDoseMedication 3AtivanDilaudidDemerolFentanylKetamineMorphineValiumVerscelDose
