Low 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 Δ
