Patient Update Form

NAME NAME

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RECOMMENDATIONS

SPA class date:
Name: MWSD
Address:
City: Postal Code:
DOB: Occupation:
Telephone: Res. Bus.
H.C. version:
Referred by: #children: / daily
3x
2x
1x
2wks
monthly
An adjustment is performed to reduce the finding of a subluxation detected through a spinal assessment on the date of the visit indicating the therapeutic necessity for chiropractic care. A subluxation or fixation/loss of joint play/biomechanical dysfunction on the day of the visit was detected through one or more of the following means: Static or motion palpation, Thompson Technique (TT), Webster Technique, Activator, Torque Release Technique (TRT) or Arm Fossa testing protocols and priorities or pre checking to observe for a physiological response prior to adjusting. An adjustment is delivered in the direction required to reduce the subluxation. The clinical notes indicate the level of malposition and the action used for the correction. In the case of extremities, a loss of joint play will be noted as the finding which was corrected.

TREATMENT/COMMENTS

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X-RAY

DATE:
VIEWS:
FINDINGS: / DATE:
VIEWS:
FINDINGS:
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C

RECOMMENDATIONS

EXAMINATION INITIAL
THERM. SEMG.

HX: Chief Complaint(s): 1°

2°

3°

Onset:

acute/subacute/chronic/recurrent/insidious

Loc/dur: occ (on & off)/freq/daily/constant

Intensity: mild/mod/severe /10, variable

Chara: dull/ache/sharp/stab/throb/burn/combo

Radiation:

Agg’d by:

Rel’d by:

Assoc Sym:

Other:

PSFA:

Prior Hx & Tx:

Sleep: (side/front/back) Smoke: Y N Quit Alcohol: Y N Occas

MD: Supplim: Y N

Rx:

Exerc:

Hered: sib: mother: father:

Progress change in symptoms: (Better, Worse, Same)

Date Date

BWS BWS

TANGENTAL OBS’N

Supports: Orthotics Cervical Pillow Braces Bite Plate

Pes planus L R: Calc Valg/Varus L R: Drop MT’s L R: Genu Valgus/Varus L R: Bunion L R

Hallus Valgus L R: Pronation L R: Supination L R: callus present:

Exam date: Re-exam date:

HT: WT: BP: (L R) PULSE PR: HR: RR:

ROM LEFT RIGHT LEFT RIGHT

C ext

C flex

C rot

C lat bend

C kemps

DIST’N/COMP’N

T/L ext

T/L flex

T/L rot

T/L Lat bend

L KEMPS

HEEL TOE WALK RHOMBERG HAUTANTS +/-

L R Musc strength L R

grip deltoid

bicep tricep

wrt flex wrt ext

finger add/abd

Hams Quads

Gluts Psoas

HipAdd HipAdb

HipFlex HipExt

DorsiFlex PlFlex

HeelButt SLR

KneeChest Fig4

Braggards Bowstrings

Valsalva/SotoHall

REFLEX L R L R

BIC TRI

BRA PAT

ACH BABINSKI

ABDOMINALS

ARM DERM

LEG DERM

Derifield: position 1 position 2

Muscle HT:

TP:

Spasm

Jumpsign Edema

CNS: olfactory dir consentual redreflex accom optic III: IV: VI: V: VII: VIII; IX; X; XI; XII
PEDIATRICS: HEAD CIRCUM: cm CHEST CIRCUM: cm NASOPALP (BLINK): P A
FONTANEL ANT: P A POST: P A PALMER GRASP: P A PLANTAR GRASP: P A
ROOTING: P A SUCKING: P A GAG: P A GALANTS: P A PEREZ: P A
MORO: P A FENCER: P A ROT’N: P A PLACING: P A STEPPAGE: P A
OTHER:

KINESIO: mild mod severe extreme MYOPATH: mild mod severe extreme

NEURO: mild mod severe extreme HISTOPATH: mild mod severe extreme

PATHOPHYS: mild mod severe extreme PHASE: I II III IV

Check if present: dyskinesia dysponesis dysautonomia/facilitation VSC

Involvement of stressors: chemical traumatic emotional/mental stress

OTHER: CHIROP IMPRESSION: