Patient Overview

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    Welcome

    Is the patient new or returning

    2Neck
    Front
    neck-front

    TransverseProcessRightTransverseProcessLeft

    Back
    neck-back

    NuchalLineNuchalLineCervicalLaminaRightCervicalLaminaLeftCervicalFacetsRightCervicalFacetsLeft
    Appearance


    Palpation
    1. Nuchal Line
    2. Cervical Lamina Right
    3. Cervical Lamina Left
    4. Cervical Facets Right
    5. Cervical Facets Left
    6. Transverse Process Right
    7. Transverse Process Left
    8. Other
    Observed Abnormality? Yes No

    Sensation Intact? Yes No

    Moves Extremities w/o Deficit? Yes No



    Procedure 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

    Procedural Sedation:
    Dose

    Dose

    Dose

    3Back
    back

    TopRightTopLeftMidRightMidLeftLowRightLowLeft
    Appearance


    Palpation
    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



    Range of Motion

    Flexion
    FullLimited    LevelPainExplain
    Extension
    FullLimited    LevelPainExplain
    Sidebending Right
    FullLimited    LevelPainExplain
    Sidebending Left
    FullLimited    LevelPainExplain
    Rotation
    FullLimited    LevelPainExplain


    Procedure 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
    Procedural Sedation:
    Dose

    Dose

    Dose

    4Low Back
    lowback

    IliolumbarLigamentRightIliolumbarLigamentLeftSIRightSILeftRightIliumLeftIliumRightLateralSacralBorderLeftLateralSacralBorder
    Appearance


    R1R2R3R4R5
    L1L2L3L4L5

    Palpation
    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



    Range of Motion

    Flexion
    FullLimited    LevelPainExplain
    Extension
    FullLimited    LevelPainExplain
    Sidebending Right
    FullLimited    LevelPainExplain
    Sidebending Left
    FullLimited    LevelPainExplain
    Rotation
    FullLimited    LevelPainExplain


    Procedure 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
    Procedural Sedation:
    Dose

    Dose

    Dose

    5Shoulder
    Front
    shoulder-front

    CoracoidProcessAnteriorHumoralHeadLateralHumoralHead

    Back
    shoulder-back

    PosteriorHumoralHeadGlenohumoralLigament
    Appearance


    Palpation
    1. Coracoid Process R L
    2. Anterior Humoral Head R L
    3. Lateral Humoral Head R L
    4. Posterior Humoral Head R L
    5. Glenohumoral Ligament R L
    6. Other
    Observed Abnormality? Yes No

    Sensation Intact? Yes No

    Moves Extremities w/o Deficit? Yes No


    Range of Motion

    Abduction
    FullLimited    LevelPainExplain
    External Rotation
    FullLimited    LevelPainExplain
    Internal Rotation
    FullLimited    LevelPainExplain
    Flexion
    FullLimited    LevelPainExplain
    Extension
    FullLimited    LevelPainExplain


    Procedure 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
    Procedural Sedation:
    Dose

    Dose

    Dose

    6Elbow
    Front
    elbow-front

    LateralEpichondyleMedialEpichondyleRadialHead
    Appearance


    Palpation
    1. Lateral Epichondyle R L
    2. Medial Epichondyle R L
    3. Radial Head R L
    4. Other
    Observed Abnormality? Yes No

    Sensation Intact? Yes No

    Moves Extremities w/o Deficit? Yes No


    Range of Motion

    Flexion
    FullLimited    LevelPainExplain
    Extension
    FullLimited    LevelPainExplain
    Supination
    FullLimited    LevelPainExplain
    Pronation
    FullLimited    LevelPainExplain


    Procedure 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
    Procedural Sedation:
    Dose

    Dose

    Dose

    7Wrist & Hand
    Front
    wristhandfront-front
    Back
    wristhand-back
    Appearance


    Palpation

    Observed Abnormality? Yes No

    Moves Extremities w/o Deficit? Yes No

    Sensation Intact? Yes No


    Range of Motion

    Flexion
    FullLimited    LevelPainExplain
    Extension
    FullLimited    LevelPainExplain
    Supination
    FullLimited    LevelPainExplain
    Pronation
    FullLimited    LevelPainExplain
    Ulnar Deviation
    FullLimited    LevelPainExplain
    Radial Deviation
    FullLimited    LevelPainExplain


    Procedure 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
    Procedural Sedation:
    Dose

    Dose

    Dose

    8Hip
    Front
    hip-front

    GreaterTrochanterPubis

    Back

    hip-back

    Ilia

    Side
    hip-side

    Appearance


    Palpation
    1. Greater Trochanter R L
    2. Pubis R R L
    3. Ilia R R L
    4. Other
    Observed Abnormality? Yes No

    Sensation Intact? Yes No

    Moves Extremities w/o Deficit? Yes No


    Range of Motion

    Flexion
    FullLimited    LevelPainExplain
    Extension
    FullLimited    LevelPainExplain
    Avduction
    FullLimited    LevelPainExplain
    Aduction
    FullLimited    LevelPainExplain
    Internal Rotation
    FullLimited    LevelPainExplain
    External Rotation
    FullLimited    LevelPainExplain


    Procedure 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
    Procedural Sedation:
    Dose

    Dose

    Dose

    9Knee
    Front
    knee

    MCLLCLPesAnserineLateralTibialPlateauMedialTibialPlateauInferiorPoleofthePatellaSuperiorPoleofthePatella
    Appearance


    Palpation
    1. MCL R L
    2. LCL R L
    3. Pes Anserine R L
    4. Lateral Tibial Plateau R L
    5. Medial Tibial Plateau R L
    6. Inferior Pole of the Patella R L
    7. Superior Pole of the Patella R L
    8. Other
    Observed Abnormality? Yes No

    Sensation Intact? Yes No

    Moves Extremities w/o Deficit? Yes No


    Range of Motion

    Valgus Stress
    FullLimited    LevelPainExplain
    Varus Stress
    FullLimited    LevelPainExplain
    Anterior Drawer
    FullLimited    LevelPainExplain
    Posterior Drawer
    FullLimited    LevelPainExplain
    Other
    FullLimited    LevelPainExplain


    Procedure 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
    Procedural Sedation:
    Dose

    Dose

    Dose

    10Ankle & Foot
    Inside
    ankle-inside

    DistalFibulaInsertionofAchillesATFLAnteriorAspectofCalcaneous

    Outside
    ankle-outside

    DistalTibia
    Appearance


    Palpation
    1. Distal Fibula R L
    2. Distal Tibia R L
    3. ATFL R L
    4. Anterior Aspect of Calcaneous R L
    5. Insertion of Achilles R L
    6. Other
    Observed Abnormality? Yes No

    Sensation Intact? Yes No

    Moves Extremities w/o Deficit? Yes No


    Range of Motion

    Plantar Flexion
    FullLimited    LevelPainExplain
    Dorsi Flexion
    FullLimited    LevelPainExplain
    Inversion
    FullLimited    LevelPainExplain
    Eversion
    FullLimited    LevelPainExplain


    Procedure 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
    Procedural Sedation:
    Dose

    Dose

    Dose

    12Other
    other

    Ribs


    Appearance

    Shins


    Appearance

    Other


    Appearance


    Membership Recommendation:

    Supplement Recommendation:

    Medication Recommendation:

    Follow Up:
    4 Weeks
    Other