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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