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