Name Date of Appointment Age Gender How Did You Hear About Us? - Select -AdvertisementReferralBlogGoogle SearchOther Complaint When Did It Start? What’s Been Done? Saw Another Doctor X-Rays MRI’s Physical Therapy Other Always Painful Frequently Painful Occasionally Painful Rarely PainfulWhat did you try? What did you do? Name Date of Appointment Complaint Always Painful Frequently Painful Occasionally Painful Rarely Painful Reason For Visit Prolotherapy Platelet Rich Plasma Stem Cell OtherLast Time Seen 4 Weeks Ago Date Action Rounds of Prolotherapy Percentage of Improvement - Select -102030405060708090100 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 NoSensation Intact? Yes NoMoves Extremities w/o Deficit? Yes NoStrength - Select -12345 Deep Tendon Reflexes - Select -01234 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 -AtivanDilaudidDemerolFentanylKetamineMorphineValiumVerscel DoseMedication 2: - Select -AtivanDilaudidDemerolFentanylKetamineMorphineValiumVerscel DoseMedication 3: - Select -AtivanDilaudidDemerolFentanylKetamineMorphineValiumVerscel Dose 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 NoSensation Intact? Yes NoMoves Extremities w/o Deficit? Yes NoStrength - Select -12345 Deep Tendon Reflexes - Select -01234 Range of MotionFlexion 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 -AtivanDilaudidDemerolFentanylKetamineMorphineValiumVerscel DoseMedication 2: - Select -AtivanDilaudidDemerolFentanylKetamineMorphineValiumVerscel DoseMedication 3: - Select -AtivanDilaudidDemerolFentanylKetamineMorphineValiumVerscel Dose Appearance NormalSwellingRednessErythemaDeformityScars R1R2R3R4R5 L1L2L3L4L5Palpation 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 NoSensation Intact? Yes NoMoves Extremities w/o Deficit? Yes NoStrength - Select -12345 Deep Tendon Reflexes - Select -01234 Range of MotionFlexion 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 -AtivanDilaudidDemerolFentanylKetamineMorphineValiumVerscel DoseMedication 2: - Select -AtivanDilaudidDemerolFentanylKetamineMorphineValiumVerscel DoseMedication 3: - Select -AtivanDilaudidDemerolFentanylKetamineMorphineValiumVerscel Dose
