prolotherapy-back

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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