LOW BACK Appearance* Normal Swelling Redness Erythema Deformity Scars OtherPalpation* 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. 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 Resolution of Symptoms? Yes No Tolerated Well? Yes No Proceedural Sedation:Medication 1AtivanDilaudidDemerolFentanylKetamineMorphineValiumVerscelDose Medication 2AtivanDilaudidDemerolFentanylKetamineMorphineValiumVerscelDose Medication 3AtivanDilaudidDemerolFentanylKetamineMorphineValiumVerscelDose
