completed formating doc

501 PAIN AND REHAB611 Court Street Suite 9, Conway, AR 72032

844-501. PAIN (7246 Office 501.358.4891 FaxDr. John D’Onofrio D.C.

Patients Name: Date:

Patients Address: City: State: Zip Code: Check which contact phone number you prefer.

Cell Phone: Text Messaging, Yes/NoHome Phone: Work Phone:

Date of Birth: Age:

Social Security No.

Date of Accident: Driver / Passenger

Amount of Property Damage to Vehicle (estimate): $

Did Pain Start Same Day?: Hospital:

MRI/CT Scan or x-rays done at Hospital, Yes / NoNature of the Problem/Areas of Pain, (Please circle what hurts, also explain when, how often?)

Neck Upper-back Mid-back Low-back Shoulder L / R Headaches Knee L / R

Job Description/Work

Accident

Auto Insurance Information: Claim # PIP, Yes / No Amount, Claim Adjuster Name: Fax No:

Health Insurance, BC/BS Aetna Cigna United Health Care Other: Identification No.

Attorney Name: Case Manager: Attorney Phone Number: Attorney Fax No.:

I agree that all information given is correct to the best of my knowledge and no false information is given. Pt. Initials:

1

INFORMED CONSENT

A patient, in coming to 501 Pain and Rehab, gives the Chiropractor permission and authority to care for the Patient in accordance with the chiropractor’s assessment of tests, diagnostic impressions, and conclusions. The Chiropractic adjustment, as well as other clinical procedures are usually beneficial and seldom cause any problem. In rare cases, underlying physical defects, deformities or pathologies may render the patient susceptible to injury. The Doctor, of course, will not give a Chiropractic adjustment, or render health care, if he or she is aware that such care may be contra indicated. It is the patient’s responsibility to make known any pathological defects, illness or deformities that would otherwise not come to the attention of the Doctor of Chiropractic. The patient should look to the correct specialist for the proper diagnostic and clinical procedures. The Doctor of Chiropractic provides a specialized, non-duplicating health service. The Doctor of Chiropractic is licensed as a specialist and is available to work with other types of providers in your health care regime.

Usually, there is a more gradual, but quite satisfactory response. Occasionally, the results are less than expected. Two or more similar conditions may respond differently to the same Chiropractic care. Many medical failures find quick relief through Chiropractic. In turn, we must admit that conditions, which do not respond to Chiropractic care, may come under the control of other health care providers. The fact is that the science of Chiropractic and medicine may never be so exact as to provide definite answers to all problems.

I understand and agree that health and accident Insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that the Doctor’s Office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to the Doctor’s Office will be credited to my account on receipt. Please discuss any questions or problems with the Doctor before signing this statement of policy.

/ / Patient’s Signature Witness’ Signature Date

CONSENT TO TREAT A MINORI, hereby authorize Dr. and whomsoever he or she may designate as assistants to administer care as deemed necessary to . My relationship to this minor is .

(Printed Name of Guardian)

/ / (Name of Minor) Parent, Guardian, or Spouse’s Signature Authorizing Care Date

CONSENT TO TREAT AN EMANCIPATED MINORBy my signature below, I warrant that I am over the age of sixteen (16) years, and that I reside separate and apart from my parents, managing conservator, or guardian. I further warrant that I am managing my own financial affairs, and hereby consent to treatment by Dallas Pain and injury.

/ / Printed Name Signature Date

INFORMED CONSENT

2

JOB DESCRIPTION AND WORK STATUS

Patient Name: M F Date / / Job Description: Job Title: Sit (hours per day): 10 8 6 4 2 1 0Stand (hours per day): 10 8 6 4 2 1 0Lift (lbs): 100 75+ 40+ 30+ 20+ 10+ Not significant Have you missed any work as a result of the accident? Y N If yes, how many days / weeks

HISTORY OF MOTOR VEHICLE ACCIDENT

Date of Injury / Accident: / / Was the Accident work-related? Y NTime of day a.m / p.m. Road conditions: IcyWet DryPolice report filed? Y N Number of people in the vehicle you occupied:

Make / model of the vehicle you occupied: Make / model of other vehicle: Were you the: Driver Passenger Sitting in the: Front Seat Back SeatOn the: Left Right CenterArea of your vehicle sustaining impact: Rear Front Left Right CenterAfter the initial collision, did any other vehicles strike your vehicle, or did your vehicle hit another vehicle or object? Y NPlease briefly describe the manner in which the collision(s) occurred:

Please, provide a diagram of the collision. Mark your car “A”, the other “B”, etc.

AS A RESULT OF THE IMPACT, YOUR BODY WAS THROWN:Back, then forward Forward, then back Left Right

Symptoms experienced immediately following accident: Symptoms experienced later that day: Symptoms experienced the following day:

Since the accident, the symptoms have: Increased Decreased Remained the sameIdentify any of the following symptoms you have been experiencing since the accident/injury:

Fatigue Y N Emotional disturbance Y N Describe: Irritability Y N Difficulty sleeping Y NNervousness Y N Weakness Y N Location:

Swelling Y N Location:

__________________________________________________ PI PERSONAL HISTORY

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PAST MEDICAL HISTORYBelow is a list of conditions that may seem unrelated to the purpose of your appointment. However, these questions must be answered carefully as these problems can affect your diagnosis, treatment plan and possibility of being accepted for care.

CHECK ANY OF THE FOLLOWING DISEASES YOU HAVE HAD:Appendicitis Malaria Diabetes ArthritisScarlet Fever Tuberculosis Cancer Venereal DiseaseDiphtheria Whooping Cough Heart Disease EpilepsyTyphoid Fever Anemia Goiter Mental DisorderPneumonia Measles Influenza LumbagoRheumatic Fever Mumps Small Pox Pleurisy EczemaPolio Chicken Pox Alcoholism NONE

CHECK ANY OF THE FOLLOWING YOU HAVE OR HAVE HAD WITHIN THE PAST 6 MONTHS:

GENERAL Allergies Loss of Sleep Fever Headaches NONE

GASTROINTESTINAL Vomiting Excessive Thirst Frequent Nausea Poor / Excessive Appetite Diarrhea Constipation Hemorrhoids Liver Trouble Gall Bladder Problems Weight Trouble Abdominal Cramps Gas / Bloating After Meals Heartburn Black / Bloody Stool Colitis NONE

FAMILY HISTORYCancer Y N Mother FatherHeart Disease Y N Mother FatherHypertension Y N Mother FatherDiabetes Y N Mother FatherStroke Y N Mother Father

EENT Ear Aches Sore Throat Dental Problems Vision Problems Stuffy Nose NONE

COMMENTS

C-V-R Chest Pain Ankle Swelling Shortness of Breath Blood Pressure Problems Irregular Heartbeat Heart Problems Lung Problems/Congestion Varicose Veins NONE

GENITOURINARY Bladder Trouble Urine Discoloration Painful/Excessive Urination NONE

FEMALES ONLYWhen was your last period? Are you pregnant? Yes No Maybe

NERVOUS SYSTEM Paralysis Forgetfulness Confusion / Depression Fainting Convulsions Cold/Tingling Extremities NONE

MALE / FEMALE Genital Herpes Vaginal Pain / Infections Breast Pain / Lumps Prostate/Sexual Dysfunction Menstrual Cramping NONE

PAST MEDICAL HISTORY

4

501 Pain and RehabUnderstanding the Importance of Following Care and Treatment

Appointments are necessary to make and keep in order for you to heal correctly and finish therapy. When appointments are missed they increase treatment time and delay the process of healing and settling your case. Missed therapy lead to the thought that you are not injured and do not need therapy.

If you have never been adjusted or received therapy, you may fell soreness or discomfort for a few hours or a few days. This is from your body and muscles getting use to the changes and being corrected much like going to the gym and feeling sore initially after a workout. This is a normal reaction to some patients initially. If soreness does occur, place ice packs @ 20 minute intervals followed by 40 minutes of rest. Do not apply ice directly to the skin.

It is important to tell the doctor if there is an increase of pain or different symptoms start to occur. This will allow him to change the treatment plan or refer out for additional tests or treatment. When pain increases medication may be needed. We do not prescribe medication at this office so referrals for medication may be made to pain management facility.

Stay away from heavy lifting or repetitive movements until the doctor indicate you are ready for normal activities.

It is also important to make your appointments for other doctors and tests. This will help assist your healing process and treatment. This will also increase the validation for injuries and support your case with the attorney or insurance. Missed appointments will make the treatment time longer, possibly change the value of your case and delay the process of setting.

My treatment dates are: Monday Tuesday Wednesday Thursday Friday Saturday At:

I have read and understand the instructions given for my follow-up care.

Patients Signature Date

5

501 Pain and RehabAFFIDAVIT AND DISCLOSURE STATEMENT

Welcome to 501 Pain and Rehab. We are pleased to have you as a prospective patient. We understand that you may have questions and concerns relating to your injuries. We want to answer all of your questions, so please ask them. We are committed to providing you with outstanding service. In order for us to comply with applicable laws and regulations, we request that you complete this form.

BY INITIALING EACH ITEM AND SIGNING BELOW, I ACKNOWLEDGE, UNDERSTAND AND CERTIFY TO 501 PAIN AND REHAB THAT:

_______ (1) I contacted 501 Pain and Rehab regarding the availability of a consultation and, if necessary, a spinal screening examination.

_______ (2) I was injured in a recent accident and have chosen to seek healthcare service at 501 Pain and Rehab on my own free will.

_______ (3) No one associated with 501 Pain and Rehab has ever made any representation to me that they, in any way affiliated with any insurance company, law enforcement agency, attorney, or law firm.

_______ (4) No one associated with 501 Paid and Rehab, including the person that initially contacted me, has paid me, or offered to pay me, or has offered to give me anything of value.

_______ (5) I am not currently seeking (and have not sought) health care from any other physician, chiropractor, medical facility, clinic, or any other provider, for my current injuries for which I am seeking treatment from 501 Paid and Rehab.

_______ (6) No one associated with 501 Pain and Rehab made any promise of a potential settlement amount and/or a time frame for such claim settlement.

_______ (7) No one associated with 501 pain and Rehab has made any promise or guarantee to me regarding the results of any treatment that I may seek from501 Pain and Rehab.

_______ (8) No one associated with 501 Pain and Rehab has slandered or spoken anything negative or derogatory towards any other clinic, medical provider, and/or medical facility of any kind.

I understand, acknowledge, and certify that all statements, information and claims that I have made, whether written or verbal, concerning my past and present medical history, my identity, and my current injuries are true and correct.

PATIENT PRINTED NAME DATE

PATIENT/GUARDIAN SIGNATURE

WITNESS SIGNATURE

6

PAIN DRAWING

ABOUT YOU

Name: Date of Accident

What is your current weight? Lbs. Height Ft./ In. Age:

Please describe your condition:

Signature: Date:

HOW US WHERE IT HURTS

Please mark area(s) of injury or discomfort on the body below. Mark all areas with the appropriate symbols.

Description Numbness Pins & Needles Burning Aching StabbingSymbol N P B A S

Circle any are of pain not represented by a symbol

Doctor’s Exam

DOCTOR’S NOTES

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POWER OF ATTORNEY

THIS Power of Attorney is given by me, (the “Principal”), presently of , , in the State of Arkansas, on this day of , .

Previous Power of Attorney

1. I REVOKE any previous power of attorney granted by me. Attorney-in-fact

2. I APPOINT Personal injury Solutions of Arkansas, Little Rock, Arkansas, to act as my Attorney-in-fact. Governing Law

3. This document will be governed by the laws of the State of Arkansas. Further, my Attorney-in-fact is directed to act in accordance with the laws of the State of Arkansas at any time he or she may be acting on my behalf. Liability of Attorney-in-fact

4. My Attorney-in-fact will not be liable to me, my estate, my heirs, successors or assigns for any action taken or not taken under this document, except for willful misconduct or gross negligence.Effective Date

5. This Power of Attorney will not come into effect until local time on the day of , 20 , and will cease to be in effect until collection of Medical Billing for 501 Pain and Rehab has been completes or settled a finding of my mental incapacity or mental infirmity which may occur after my execution of this Power of Attorney.

Powers of Attorney-in-fact

6. My Attorney-in-fact will have the following powers(s):

a. This power of Attorney is a limited power of Attorney, exclusively allowing Personal Injury Solutions to collect medical billing owed by me on behalf of 501 Pain and Rehab for treatment received at 501 pain and Rehab. They may speak on my behalf regarding my bill at the clinic and collect monies owed to them by the insurance company. My contact with the insurance company will not be necessary for collection of the 501 Pain and Rehab Bill.

8

Delegation of Authority

7. My Attorney-n-fact may not delegate any authority granted under this document.

Notice to Third Parties

8. Any third party who receive a valid copy of this Power of Attorney can rely on and act under it. A third party who relies on the reasonable representations of my Attorney-in-fact as to a matter relating to a power granted by this Power of Attorney will not incur any liability to the Principal or to the Principal’s heirs, assigns, or estate as a result of permitting the Attorney-in-fact to exercise the authority granted by this Power of Attorney up to the point o revocation of this Power of Attorney. Revocation of this Power of Attorney will not be effective as to a third party until the third party receives notice and has actual knowledge of the revocation. Acknowledgment

9. I, , being the Principal named in this Power of Attorney hereby acknowledge:

a. I have read and understand the nature and effect of this Power of Attorney. b. I am of legal age in the State of Arkansas to grant a Power of Attorney; and c. I am voluntarily giving this Power of Attorney.

IN WITNESS WHEREOF I hereunto set my hand and seal at the City of in the State of Arkansas, this day of , ,

Signature of Principal

Printed Name

NOTARY ACKNOWLEDGMENT

STATE OF ARKANSAS

COUNTY OF

The instrument was acknowledged before me on the day of , , by .

Notary Public

My commission expires:

9

This notice describes how your health information may be used and how you can gain access to this information. Please review it carefully.

Our Promise to You our Valued Patient…This is not meant to alarm you. Quite the opposite. We want to assure you that we take the Federal HIPPA (Health Insurance Portability and

Accountability Act) law seriously. These laws were written to protect the confidentiality of your health information. We trust you will never delay treatment in our office because of fear that your personal health information might be unnecessarily disclosed to other outside our office.

Why A Privacy Policy Now?The most significant variable that has motivated the Federal government to legally enforce the privacy of health information is the rapid evolution of

the use of electronic technology in the administration of health care business. The government has appropriately sought to standardize and protect the electronic exchange of your health information. This has challenged us to review not only how your information is used within our computer, but also with the Internet, phones, fax machines and any devise used to copy or transfer that data. We want to advise you that we have developed policies and procedures for our practice to assure that you’re personal or health information will be shared only s required and only for the purpose of administering your case. Our office is subject to State and Federal laws regarding the confidentiality of your health information. We will assure our adherence to those laws and we want you to understand our procedures and your rights as a valued patient. Your health information will be communicated only for the purpose of conducting health care business and obtaining payment for services. Be assured that without your written permission, your health information will not be used for any other purpose.

How Your Health Information May be Used To Provide Treatment. Within our office, you’re your health information will be used to provide you the best care and services possible. This may include administrative and

clinical procedures designed to optimize scheduling and coordination between you and all office personnel. I addition, we may share this information with referring physicians, clinical pathology laboratories or other health professionals providing you treatment. Your health information may be included with an invoice for the purpose of collecting payment for services provided to you in the office. We may do this with insurance forms filed for your by mail or electronically. We will make every effort to work with companies with a similar commitment to the security of your health information.

To Conduct Health Care OperationsYour health information may be used during performance evaluations of our staff. Some of our best teaching opportunities use clinical situations

experienced by patients receiving care in our office. As a result your health information may be included in the training programs for associates and business and clinical employees. It is also possible that your health information will be disclosed during audits by insurance companies or government appointed agencies as part of their quality assurance and compliance reviews. Your health information may be reviewed during the routine process of certification, licensing credentialing activities.

Public Health and National SecurityWe may be required to disclose to Federal officials or military authorities health information necessary to complete an investigation related to public

health and or national security.

For Law EnforcementAs permitted or required by State or Federal law, we many disclose your health information to proper authorities for the purpose of law enforcement

including, under certain circumstances, if you are a victim of a crime or in order to report a suspected crime.

Family, Friends and Care givers We may share your health information with those you tell us will be assisting you with your home hygiene, care, treatment or payment. We will be

certain to obtain your permission prior to sharing your information. In the event of an emergency, if you are unable to tell us what you want, we will use our very best judgment when sharing your health information with anyone participating in your care. Advancing health care knowledge often involves learning from the careful study of health histories of prior patients. Formal review and study of health histories as a part of a research study will happen only under the ethical guidance, requirements, and approval of an Institutional Review Board.

Authorization To Use or Disclose Health InformationOther than is stated above or where Federal, State or Local law requires us, we will not disclose your health information other than with your written

authorization. You may revoke that authorization in writing at any time.

Parties RightsThis law is careful to describe that you have the following rights related to your health information. Be assured that our office will make every effort to

honor reasonable restriction preferences from our patients.

Right To Reserve Privacy Practices As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be

required by changes in federal and state laws and regulations. Whatever the reason for these revisions, we will provide you with a revised notice on your next visit. The revised policies and practices will be applied to all protected health information that we maintain.

Requests To Inspect Protected Health InformationAs permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing.

I have read and received a copy of Health Choice Chiropractic & Massage’s Privacy Practices.

Patient Signature Date __ / /

10

Musculoskeletal Examination

Patient Name Age: Date: New Established

*CONSTITUTIONAL * CARDIOVASCULARVitals: (any three) L R General Appearance Peripheral vascular System (by observation & Palpation)

BP – Sit/StandDevelopment:Nutrition:

Pulse Body habits:Weight/Height Deformities:Respiration Grooming:Temperature No apparent deformities.

Swelling: Normal Varicosities: Normal Pulse: Normal Temperature: Normal Edema: Normal Tenderness Normal

Additional Comments Additional Comments:

*SKIN* LYMPHATICInspection and/or palpation – any four (ALL for comprehensive Exam)

Check for scars Rashes Lesions Café-au-lait spots-Ulcers-BruisesPalpation – (any one or more area)Check for any abnormalities

Head & Neck: Within Normal Limits Neck: Within Normal LimitsTrunk: Within Normal Limits Axillae: Within Normal LimitsRight Upper Extremity: Within Normal Limits Groin : Within Normal LimitsLeft Upper Extremity: Within Normal Limits Others: Within Normal LimitsRight Lower Extremity: Within Normal Limits Additional Comments:Left Lower Extremity: Within Normal Limits

*NEUROLOGICAL EXAM / MUSCLE STRENGTH* ORTHOPENDIC EXAMCoordination L R WNL Dermatome

( + ) WNLFinger to NoseRapid Mvmts C5

C6Young Children C7Fine Motor Skill C8Reflexes L R WNL T1Biceps L3Triceps L4Patellar L5Achilles S1Muscle Strength L R Gait & StationDeltoid /5 /5 Gait: NormalBiceps /5 /5 Tandem Walk: NormalTriceps /5 /5 Toe Walk: NormalWrist Flex /5 /5 Heel Walk : NormalWrist Ext /5 /5 Romberg’s: NormalThumb/Opps /5 /5Neck Flex /5 /5 *PSYCHIATRIC*SCM /5 /5 Orientation: Time/Place/PersonHip Flex /5 /5 Oriented Disoriented Hamstrings /5 /5 Mood & AffectKnee Ext /5 /5 Normal Anxious

Depressed Agitated Distressed – Due to pain

Dorsal Flex /5 /5Psoas /5 /5

Cervical L R Notes:Neutral CompressionLateral CompressionForaminal Compression Cervical DistractionShoulder Compression

Lumbar L R Notes:Straight Leg Raise PainMilgramsPatrick FabereElyHibbsYeoman’sKempsValsalva

Comments:

Comments:

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MUSCULOSKELETAL EXAMINATION

Patient Name: DateStep 1-Add up Problem Points Medical Decision making

PointsStep 2 – Add up data Points Points

Self-limited or minor (maximum of 2) 1 Review or order clinical lab test 1Established problem, stable or improving 1 Review or order radiology test 1Established problem, worsening 2 Review or order medicine test 1New problem, with no additional work-up planned (maximum of 1)

3 Discuss test with performing Physician 1

New problem, with additional work-up planned.

4 Independent review of image 2

TotalDecision to obtain old records 1Review and summation of old records 2

TotalStep 3 – Select Risk (Requires ONE from Any Category)

Presenting Problems DiagnosticMINIMAL One – Self Limited/Minor X-rays Rest

Low

Two or more self limited or minor

One-Stable Chronic illness

Acute uncomplicated injury: Simple Sprain

Physiologic tests Chiropractic Care

Physical therapy

Occupational therapy

Moderate

One or more chronic illnesses w/mild exacerbation,

progression, or side effects of treatment

Two or more stable chronic illnesses

Undiagnosed new problem with uncertain prognosis

Acute complicated injury

Physiologic tests under stress

Diagnostic endoscopies with no

identified risk factors

Deep needle or incision biopsy

Minor Surgery w/risk

Elective major surgery w/no

identified risk

Prescription drugs

High One or more chronic illnesses chronic ilnesses with severe exacerbation, probression, or side effects of treatment

An abrupt change in neurologic status, e.g. seizure, TIA, weakness or sensory loss

Step 4 – Calculate Level of Medical Decision MakingCircle the number of PROBLEM and DATA points, then circle the level of RISK History

Exam

MD

99201 99202 99203 99204 99205

99201 99202 99203 99204 99205

99201 99202 99203 99204 99205

Straightforward <1 <1 Minimal 99201 99202 99212 99213Low 2 2 Low 99203 99214 History 99211 99212 99213 99214 99215

99211 99212 99213 99214 99215 99211 99212 99213 99214 99215

Moderate 3 3 Moderate 99204 99215 ExamHigh >4 >4 High 99205 MDM

Doctor’s OrdersCervical AP & Lateral With Open Mouth Flexion/ExtensionThoracic AP & Lateral BendingLumbar AP & Lateral Oblique BendingPelvis/Sacral 1 viewExtremity Upper _______________________________ Lower: ___________________________Other ____________________________________

NCV / EMG Cervical / Upper Extremity Lumbar / Lower Extremity MRI / CT Cervical Thoracic Lumber Other _______________________________Functional Capacity _________________________________________ Pain Management: ____________________________Non Invasive Vascular Upper Lower Extremities Include Duplex Scan Include Duplex Scan, Extra CranialMRI Cervical Thoracic Lumber / Sacrum Other ______________________________________

DME Lumber Support T.E.N.S Cervical/Lumber Pump Cryo/Thermal Unit Other ___________________TREATMENT PLAN

Rule Out Pathology Passive _______ x ________ CMT Electro H/C IST MT/MS Rehab Rocker/UBE Radicular Symptoms(s) Headaches High Risk PRSH Therapy / Rehab Deformity and / or immobility Phase I _______ x ________ CMT Electro H/C IST MT/MS Rehab Rocker/UBE Long Term Recurring Pain Phase I _______ x ________ CMT Electro H/C IST MT/MS Rehab Rocker/UBE Neurological Signs Phase I _______ x ________ CMT Electro H/C IST MT/MS Rehab Rocker/UBE Rule Out Contraindications to Chiropractic Manipulation Maintenance ________ x Month IST MS Other

Doctor’s Signature

12


Patient Name: Date:PAIN ASYMMETRY R.O.M.

Misalignment TISSUE

Right Left Both

L R Head Mid Back Shoulder Arm Hand

Dull Stiff Ache Sharp Throbbing Stabbing Numbness Tingling Worsening Constant Intermittent W/Mvmnt

(Circle)0 12 34 56 78 9

10 +

Movement Palpation Activities

Flex 50Ext 60L Lat 45R Lat 45L Rot 80R Rot 80 Crepitation Contracture

Edema Inflammation Cut Scraped Masses Bruised Effusion

Rigid Tight Coarse Contracted Inflamed Tension

Tight Weak Contracture Swelling Trigger Points(s) __________ Edema Spasms

Instability Stiff Laxity

*HEAD

&

NECK*

PAIN ASYMMETRY R.O.M.Misalignment

TISSUE

Right Left Both

L R Shoulder Arm Chest Rib(s) Side L R


(Circle)0 12 34 56 78 9

10 +

Movement Palpation Activities Deep Breath Coughing Sneezing

Flex 60Ext 25L Lat 25R Lat 25L Rot 45R Rot 45 Crepitation Contracture

Notes

Pain:Asymmetry:R.O.M:Tissue:List Specific Misalignments(s)





*SPINE

RIBS

&

PELVIS*


TISSUE

Right Left Both

L R Hip/Groin Buttock Thigh Knee Foot/Toe


(Circle)0 12 34 56 78 9

10 +


Notes:

Flex 60Ext 25L Lat 25R Lat 25L Rot 45R Rot 45 Crepitation ontracture

Notes

Pain:Asymmetry:R.O.M:Tissue:List Specific Misalignments(s)





13


Patient Name: Date:PAIN ASYMMETRY R.O.M.

Misalignment TISSUE

Right Left Both



(Circle)0 12 34 56 78 9

10 +

Movement Palpation Activities

Notes: Notes:

Fixated Pain

Restricted Pain

Within Normal Limits Pain

Crepitation Contracture





*SPINE

RIBS

&

PELVIS*

*LOWER

EXTREMITY*


TISSUE

Right Left Both



(Circle)0 12 34 56 78 9

10 +


Notes:-

Fixated Pain

Restricted Pain

Within Normal Limits Pain

Crepitation Contracture





UPPER EXTREMITY

LOWER EXTREMITY

Dawbarn’s Finklestein’sAppley’s Scratch

Phalen’s

Dugas ELBOWFlexion

PAINRev. Phalen’sFroment’s

Extension Tinel’sOTHER PAIN

ValgusVarus

Location Quality:M P PainA A ACHER N NumbK T Tingle

VAS Intensity:1 2 3 4 5 6 7 8 9 10

Use arrows:

R-Restricted F-Fixated CR-Crepitation

Skin: C – Cut B-Bruised E – EffusionFascia: R – Rigid TT – Tight CS - CoarseMuscle: TT – Tight W – Weak S – Spasm CT – Contracture SW – Swelling ED – Edema TP – Trigger Point(s)Ligament: I – Instability ST - Stiff

HIP PAIN KNEE PAINLaguerre ANKLE/FOOTFoot Drawer PAIN

A-P DrawerP-A DrawerApley’s Compression

Neuroma Squeeze

Apley’s Distraction

Inversion Test DryersEversion Test

Tinel’s Foot Test

Step 1 Determine the number of body are examined Step 2 Count Points

Step 3 Circle Level of Exam

Head & NeckSpine, Ribs & PelvisRight Upper ExtLeft Upper ExtRight Lower ExtLeft Lower Ext

1-5 99201, 992136-11 99202, 9921312+ 99203, 99214

All * ‘d pointsPLUS 1 Cardio & 1 Lymph

99204 99215 99205MEDICARE:- To demonstrate subluxation based with physical exam 2 of the 4 (Pain, Asym, ROM, Tissue) are required for each area: C, T, L, Sat Pelvis to

14

Circle

be diagnosed and adjusted. One of the two must be either Asymmetry/misalignment or ROM.

15

501 Pain and Rehab611 Court Street Suite 9Conway, AR 72032

DOCTOR’S LIEN

To Adjuster/Attorney

I do hereby authorize the above doctor to furnish you, my attorney/adjuster, with a full report of his examinations, diagnosis, treatment, prognosis, etc., of myself in regards to the accident in which I was involved.

I hereby authorize and direct you, my attorney/adjuster, to pay directly to said doctor such sums as may be due and owing him for medical services rendered me both by reason of this accident and by reason of any other bills that are due his office and to withhold such sums from any settlement, judgment, or verdict as may be necessary to adequately protect said doctor. And, I hereby further give lien on my case to said to doctor against any and all proceeds of any settlement, judgment, or verdict which may be paid to my attorney or myself as the result of the injuries for which I have been treated or injuries in connection therewith.

I fully understand that I am directly and fully responsible to said doctor for all medical bills submitted by him for services rendered me and that this agreement is made solely for said doctors additional protection and in consideration of his awaiting payment. And, I further understand that such payment is not contingent on any settlement, judgment, or verdict that I may eventually recover said fee.

Dated: Patient’s Signature:

Patient’s Name:

The undersigned being attorney/adjustor of records for the above patient does hereby agree to observe all the terms of the above and agrees to withhold such sums from any settlement, judgment, or verdict as may be necessary to adequately protect said doctor above named.

Dated: Attorney’s Signature:

Attorney’s Name:

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