Name Date of Appointment Age Gender How Did You Hear About Us? - Select - Advertisement Referral Blog Google Search Other 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 Painful What 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 Other Last Time Seen 4 Weeks Ago Date Action Rounds of Prolotherapy Percentage of Improvement - Select - 10 20 30 40 50 60 70 80 90 100 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 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 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
