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S/T THERAPY - ( ) ELECTROTHERAPY - ( )
Name
DOB / /
WORKING
DIAGNOSIS
DATE
1
2
3
MUSCLE WEAKNESS, BLADDER/BOWEL
GROIN NUMBNESS, SENSATION CHANGE
FLAGS
( )
SAME
DIAG.
MILD
MODERATE
SEVERE
KEY
TEST DONE
CIRCLE OR
TICK
SUBJECTIVE COMPLAINT(S):
WORSE SAME
, , EASIER, ALOT EASIER, VERY GOOD. (10 = SEVERE, 1= MILD) 0 1 2 3 4 5 6 7 8 9 10 N / A
Occ
C1
C2
C3
C4
C5
C6
C7
T1
T2
T3
T4
T5
T6
T7
T8
T9
T10
T11
T12
L1
L2
L3
L4
L5
Sac
Coc
R
PERCENTAGE PROBLEM IMPROVED WITH TREATMENT: 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% N / A
AREAS: - NECK / DORSAL / LB / PELVIC / MAINT / OTHER -:
OBJECTIVE FINDINGS:
MOVEMENT/ LOCOMOTION: NORM, GUARDED, ABNOR, RESTRICTED, OTHER:
PALPATION /OBSERVATION: TENDERNESS, M.SPASM, NUMBNESS, SWELLING, FIXATION, HYPERMOBILITY, ATROPHY. OK
PLAN: ICE, REST, HEAT, SHORT WALKS, DIET, SUPPORT, POSTURAL ADVICE,
FIXATIONS
O = STIFF
OO = V. STIFF
X = PAINFUL
XX = V. PAINFUL
ASSESSMENT / TESTS / RX: SLR ( L ) ( R ), SLUMP ( L ) ( R ), TOE EXTENSORS ( L ) ( R ), S1 REFLEX ( L ) ( R ),
ADVICE AT WORK, TAPING, NSAIDS, PARACETAMOL, EXERCISES - ( )
SIGNED
NEXT APPOINTMENT
POST TREATMENT
PAIN FREQUENCY TRACE 20 30 40 50 60 70 80 90 100% ZERO
10% OF DAY
No
WORKING
DIAGNOSIS
DATE
1
2
3
MUSCLE WEAKNESS, BLADDER/BOWEL
GROIN NUMBNESS, SENSATION CHANGE
FLAGS
SUBJECTIVE COMPLAINT(S):
WORSE SAME
, , EASIER, ALOT EASIER, VERY GOOD. (10 = SEVERE, 1= MILD) 0 1 2 3 4 5 6 7 8 9 10 N / A
Occ
C1
C2
C3
C4
C5
C6
C7
T1
T2
T3
T4
T5
T6
T7
T8
T9
T10
T11
T12
L1
L2
L3
L4
L5
Sac
Coc
R
PERCENTAGE PROBLEM IMPROVED WITH TREATMENT: 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% N / A
AREAS: - NECK / DORSAL / LB / PELVIC / MAINT / OTHER -:
OBJECTIVE FINDINGS:
MOVEMENT/ LOCOMOTION: NORM, GUARDED, ABNOR, RESTRICTED, OTHER:
PALPATION /OBSERVATION: TENDERNESS, M.SPASM, NUMBNESS, SWELLING, FIXATION, HYPERMOBILITY, ATROPHY. OK
PLAN: ICE, REST, HEAT, SHORT WALKS, DIET, SUPPORT, POSTURAL ADVICE,
FIXATIONS
O = STIFF
OO = V. STIFF
X = PAINFUL
XX = V. PAINFUL
ASSESSMENT / TESTS / RX: SLR ( L ) ( R ), SLUMP ( L ) ( R ), TOE EXTENSORS ( L ) ( R ), S1 REFLEX ( L ) ( R ),
ADVICE AT WORK, TAPING, NSAIDS, PARACETAMOL, EXERCISES - ( )
SIGNED
NEXT APPOINTMENT
POST TREATMENT
( )
SAME
DIAG.
MILD
MODERATE
SEVERE
WORKING
DIAGNOSIS
DATE
1
2
3
MUSCLE WEAKNESS, BLADDER/BOWEL
GROIN NUMBNESS, SENSATION CHANGE
FLAGS
SUBJECTIVE COMPLAINT(S):
WORSE SAME
, , EASIER, ALOT EASIER, VERY GOOD. (10 = SEVERE, 1= MILD) 0 1 2 3 4 5 6 7 8 9 10 N / A
Occ
C1
C2
C3
C4
C5
C6
C7
T1
T2
T3
T4
T5
T6
T7
T8
T9
T10
T11
T12
L1
L2
L3
L4
L5
Sac
Coc
R
PERCENTAGE PROBLEM IMPROVED WITH TREATMENT: 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% N / A
AREAS: - NECK / DORSAL / LB / PELVIC / MAINT / OTHER -:
OBJECTIVE FINDINGS:
MOVEMENT/ LOCOMOTION: NORM, GUARDED, ABNOR, RESTRICTED, OTHER:
PALPATION /OBSERVATION: TENDERNESS, M.SPASM, NUMBNESS, SWELLING, FIXATION, HYPERMOBILITY, ATROPHY. OK
PLAN: ICE, REST, HEAT, SHORT WALKS, DIET, SUPPORT, POSTURAL ADVICE,
FIXATIONS
O = STIFF
OO = V. STIFF
X = PAINFUL
XX = V. PAINFUL
ASSESSMENT / TESTS / RX: SLR ( L ) ( R ), SLUMP ( L ) ( R ), TOE EXTENSORS ( L ) ( R ), S1 REFLEX ( L ) ( R ),
ADVICE AT WORK, TAPING, NSAIDS, PARACETAMOL, EXERCISES - ( )
SIGNED
NEXT APPOINTMENT
POST TREATMENT
( )
SAME
DIAG.
MILD
MODERATE
SEVERE
PAIN FREQUENCY TRACE 20 30 40 50 60 70 80 90 100% ZERO
10% OF DAY
PAIN FREQUENCY TRACE 20 30 40 50 60 70 80 90 100% ZERO
10% OF DAY
NOTES
MANIPULATION -
S/T THERAPY - ( ) ELECTROTHERAPY - ( )
S/T THERAPY - ( ) ELECTROTHERAPY - ( )
MANIPULATION -
MANIPULATION -