SUBJECTIVE

Patient Chief Complaint(s)

Description / Mechanism of Injury:

Location:

Pain Score

On a scale of 0 to 10, with 0 being no pain and 10 being the worst pain imaginable, how would you rate your pain right now?

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Pain context

Body site

Search Body site

Laterality

Select laterality...

Pain context

Current

Related condition

Search Related condition

Status

Active

Notes

Document quality, relief factors, and aggravating factors...

Impact on Activities of Daily Living:

Frequency:

Radiation:

Aggravated by:

Alleviated by:

Other details and updates:

Past Medical History

Prior chiropractic / physical therapy care:

Prior surgeries:

Medical conditions:

Current medications:

Allergies:

Red Flag Screening

No red flags identified

Unexplained weight loss

Fever / Chills

Bowel / Bladder changes

Progressive neurological deficit

Night pain unrelieved by rest

Changes Since Last Visit

Patient experienced these changes since their last visit:

Significantly better

Moderately better

Slightly better

No different

Slightly worse

Moderately worse

Significantly worse

OBJECTIVE

Blood Pressure

Systolic · mmHg

Diastolic · mmHg

Heart rate · bpm

Anthropometrics

Weight · kg

KG LB

Height · cm

CM FT/IN

Temperature · °C

°C °F

Notes

Muscular Analysis

Spinal Analysis

Region	Findings
Cervical
Thoracic
Lumbar
Sacrum / Sacroiliac

Extra-Spinal Analysis

Joint	Findings
Shoulder
Elbow
Wrist
Hip
Knee
Ankle

Neurological Tests

Test	Findings
DTRs
Sensory
Motor
Straight Leg Raise

Orthopedic Tests

Test	Findings
Kemp's
Patrick's / FABER
Compression / Distraction
Spurling's

Imaging Review

Pain Interference (BPI-SF)

Front

Back

Pain Severity

Worst Pain

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Least Pain

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Average Pain

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Current Pain

012345678910

Pain Relief

Pain Relief Percent

0% 100%

Pain Interference

General Activity

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Mood

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Walking Ability

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Normal Work

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Relations with Others

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Sleep

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Enjoyment of Life

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Notes

Pain quality, treatments, response, daily impacts...

Assessment Scores

(e.g., Neck Disability Index, Low Back Disability)

Range of Motion Review

Region / Joint	ROM Findings
Cervical Spine
Thoracic Spine
Lumbar Spine
Shoulder
Elbow
Wrist
Hip
Knee
Ankle

ASSESSMENT

Overall Description:

Diagnosis Search

Primary diagnosis

Coding Details

Status

Select status...

Severity

Select severity...

Onset Date

YYYY-MM-DD

Resolved Date

YYYY-MM-DD

Diagnosis Search

Secondary diagnosis

Coding Details

Status

Select status...

Severity

Select severity...

Onset Date

YYYY-MM-DD

Resolved Date

YYYY-MM-DD

Prognosis:

Progress Since Last Visit

Condition has resolved

Marked improvement

Moderate improvement

Slight improvement

No change

Slight worsening

Moderate worsening

Marked worsening

PLAN

Today's Treatment

Treatment Modalities (check all performed):

CMT / Spinal adjustment

Soft tissue therapy / Myofascial release

Electrical stimulation (E-stim)

Therapeutic ultrasound

Traction / Decompression

Ice / Heat therapy

Therapeutic exercise / Rehab

Kinesio tape / Bracing

Treatment Notes:

Treatment Plan

Category	Details
Labs Ordered
Referrals Needed
Lifestyle
Diet / Nutrition
Activity / Exercise
Mind / Body

Supplements (if needed)

Regimen Name

Protocol Phase

Select Phase

Duration

New Supplement

Supplement Name

Form

Select

Strength Value

e.g. 200 mg

Dose Amount

Route

Select

Frequency

Select

Instructions

Adherence

Select

Start Date

yyyy-mm-dd

Stop Date

yyyy-mm-dd

Taper Details

Adverse Effects

+ Add Supplement

Protocols Shared

Follow-Up

Return in:

Re-evaluation in:

Patient education provided:

SUBJECTIVE

Patient Chief Complaint(s)

Pain NRS

Past Medical History

Red Flag Screening

Changes Since Last Visit

OBJECTIVE

Vitals

Muscular Analysis

Spinal Analysis

Extra-Spinal Analysis

Neurological Tests

Orthopedic Tests

Imaging Review

Pain Interference (BPI-SF)

BPI-SF

Assessment Scores

Range of Motion Review

ASSESSMENT

Diagnosis Snapshot

Diagnosis Snapshot

Progress Since Last Visit

PLAN

Today's Treatment

Treatment Plan

Supplements (if needed)

Supplement Regimen

Supplement Items

Protocols Shared

Follow-Up

Chiropractic Initial Consultation Note

Preview