Welcome Is the patient new or returning NewReturning 2Neck Front Back Appearance NormalSwellingRednessErythemaDeformityScars 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 Strength - Select - 1 2 3 4 5 Deep Tendon Reflexes - Select - 0 1 2 3 4 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: Medication 1: - Select - Ativan Dilaudid Demerol Fentanyl Ketamine Morphine Valium Verscel Dose Medication 2: - Select - Ativan Dilaudid Demerol Fentanyl Ketamine Morphine Valium Verscel Dose Medication 3: - Select - Ativan Dilaudid Demerol Fentanyl Ketamine Morphine Valium Verscel Dose 3Back Appearance NormalSwellingRednessErythemaDeformityScars 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 Strength - Select - 1 2 3 4 5 Deep Tendon Reflexes - Select - 0 1 2 3 4 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: Medication 1: - Select - Ativan Dilaudid Demerol Fentanyl Ketamine Morphine Valium Verscel Dose Medication 2: - Select - Ativan Dilaudid Demerol Fentanyl Ketamine Morphine Valium Verscel Dose Medication 3: - Select - Ativan Dilaudid Demerol Fentanyl Ketamine Morphine Valium Verscel Dose 4Low Back Appearance NormalSwellingRednessErythemaDeformityScars 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 Strength - Select - 1 2 3 4 5 Deep Tendon Reflexes - Select - 0 1 2 3 4 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: Medication 1: - Select - Ativan Dilaudid Demerol Fentanyl Ketamine Morphine Valium Verscel Dose Medication 2: - Select - Ativan Dilaudid Demerol Fentanyl Ketamine Morphine Valium Verscel Dose Medication 3: - Select - Ativan Dilaudid Demerol Fentanyl Ketamine Morphine Valium Verscel Dose 5Shoulder Front Back Appearance NormalSwellingRednessErythemaDeformityScars 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 Strength - Select - 1 2 3 4 5 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: Medication 1: - Select - Ativan Dilaudid Demerol Fentanyl Ketamine Morphine Valium Verscel Dose Medication 2: - Select - Ativan Dilaudid Demerol Fentanyl Ketamine Morphine Valium Verscel Dose Medication 3: - Select - Ativan Dilaudid Demerol Fentanyl Ketamine Morphine Valium Verscel Dose 6Elbow Front Appearance NormalSwellingRednessErythemaDeformityScars 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 Strength - Select - 1 2 3 4 5 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: Medication 1: - Select - Ativan Dilaudid Demerol Fentanyl Ketamine Morphine Valium Verscel Dose Medication 2: - Select - Ativan Dilaudid Demerol Fentanyl Ketamine Morphine Valium Verscel Dose Medication 3: - Select - Ativan Dilaudid Demerol Fentanyl Ketamine Morphine Valium Verscel Dose 7Wrist & Hand Front Back Appearance NormalSwellingRednessErythemaDeformityScars Palpation Observed Abnormality? Yes No Moves Extremities w/o Deficit? Yes No Sensation Intact? Yes No Strength - Select - 1 2 3 4 5 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: Medication 1: - Select - Ativan Dilaudid Demerol Fentanyl Ketamine Morphine Valium Verscel Dose Medication 2: - Select - Ativan Dilaudid Demerol Fentanyl Ketamine Morphine Valium Verscel Dose Medication 3: - Select - Ativan Dilaudid Demerol Fentanyl Ketamine Morphine Valium Verscel Dose 8Hip Front Back Side Appearance NormalSwellingRednessErythemaDeformityScars 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 Strength - Select - 1 2 3 4 5 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: Medication 1: - Select - Ativan Dilaudid Demerol Fentanyl Ketamine Morphine Valium Verscel Dose Medication 2: - Select - Ativan Dilaudid Demerol Fentanyl Ketamine Morphine Valium Verscel Dose Medication 3: - Select - Ativan Dilaudid Demerol Fentanyl Ketamine Morphine Valium Verscel Dose 9Knee Front Appearance NormalSwellingRednessErythemaDeformityScars 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 Strength - Select - 1 2 3 4 5 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: Medication 1: - Select - Ativan Dilaudid Demerol Fentanyl Ketamine Morphine Valium Verscel Dose Medication 2: - Select - Ativan Dilaudid Demerol Fentanyl Ketamine Morphine Valium Verscel Dose Medication 3: - Select - Ativan Dilaudid Demerol Fentanyl Ketamine Morphine Valium Verscel Dose 10Ankle & Foot Inside Outside Appearance NormalSwellingRednessErythemaDeformityScars 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 Strength - Select - 1 2 3 4 5 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: Medication 1: - Select - Ativan Dilaudid Demerol Fentanyl Ketamine Morphine Valium Verscel Dose Medication 2: - Select - Ativan Dilaudid Demerol Fentanyl Ketamine Morphine Valium Verscel Dose Medication 3: - Select - Ativan Dilaudid Demerol Fentanyl Ketamine Morphine Valium Verscel Dose 12Other Ribs Appearance SwellingRednessErythemaDeformityScars Shins Appearance SwellingRednessErythemaDeformityScars Other Appearance SwellingRednessErythemaDeformityScars Membership Recommendation: Supplement Recommendation: Medication Recommendation: Follow Up: 4 Weeks Other previousnext
