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As Seen On...
Front

6 7
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

Strength12345

Deep Tendon Reflexes01234


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