Patient Portion

The first part of the form is for the patient to complete. The date, name and age are completed, along with a brief description of why they came in for a visit.

Pain

• “X’s” are placed on areas causing pain. Qualify the pain with a letter, i.e., “A“ for “Ache.”
• The patient completes the Pain scale by circling a number.

History

• The patient also completes a brief health history and signs the form.

Office Portion

Range of motion: Range of motion can be filled out by a well-trained CA. By the time the DC sees the patient much of the form will be completed. The DC will follow up to the past health history with the appropriate questions asking about family, social, occupational, and their health habits.

Asymmetry: The initial evaluation of asymmetry can be accomplished by looking at the patient standing. The arrows show high or low illi, shoulders. Misaligned vertebrae can be motion palpated for fixations and statically palpated, the level being marked with arrows in terms of misalignment.

Tissue: Palpation of muscle tissue can be recorded on the muscle diagram, noting specific problems using the appropriate code.

HX of Present Complaint: The history of the presenting complaint can be done first, or after the health history is reviewed; it is up to the practitioner. There is room for the basic exam findings to include muscle testing, general ortho/neuro testing and reflexes. Comments or more specific ortho/neuros can be recorded under notes. The treatment plan is then considered, a diagnosis is made and the form is dated and signed. Depending on how much help a DC has from their CA, the DC exam takes no more than 15 to 25 minutes to complete.

CLICK HERE to download the form.