test-knee

As Seen On...

    Name
    Date of Appointment
    Age Gender


    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

    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

    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

    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