Patient Overview

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2Neck
Front
neck-front

TransverseProcessRight TransverseProcessLeft

Back
neck-back

NuchalLine NuchalLine CervicalLaminaRight CervicalLaminaLeft CervicalFacetsRight CervicalFacetsLeft
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

TopRight TopLeft MidRight MidLeft LowRight LowLeft
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

IliolumbarLigamentRight IliolumbarLigamentLeft SIRight SILeft RightIlium LeftIlium RightLateralSacralBorder LeftLateralSacralBorder
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

CoracoidProcess AnteriorHumoralHead LateralHumoralHead

Back
shoulder-back

PosteriorHumoralHead GlenohumoralLigament
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

LateralEpichondyle MedialEpichondyle RadialHead
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

GreaterTrochanter Pubis

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

MCL LCL PesAnserine LateralTibialPlateau MedialTibialPlateau InferiorPoleofthePatella SuperiorPoleofthePatella
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

DistalFibula InsertionofAchilles ATFL AnteriorAspectofCalcaneous

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