| Patient Name: | |||||
| Date | Pain Tenderness Spasm Radiating Inflammation Par aesthesia Weakness Dec. R.O.M. Stiff/Tight |
Manipulation Neur.Mus.ReEd +Ortho. Test +Neuro. Test Deep Tis. Mass. Ultrasound Traction Heat Cryo Tx. Elect.Mus. Stim. |
Chronic/Acute Constant Frequent Intermittent Occasional Severe Moderate Slight Mild |
T.M.J. Occiput C 1234567 T 123456789101112 L 12345 Sac./Coccyx/Pelvis Posture Supports Supplements |
Exacerbated Same Improving Prognosis: Good Unable To Determine Guarded Poor Initials: |
| Date | Pain Tenderness Spasm Radiating Inflammation Par aesthesia Weakness Dec. R.O.M. Stiff/Tight |
Manipulation Neur.Mus.ReEd +Ortho. Test +Neuro. Test Deep Tis. Mass. Ultrasound Traction Heat Cryo Tx. Elect.Mus. Stim. |
Chronic/Acute Constant Frequent Intermittent Occasional Severe Moderate Slight Mild |
T.M.J. Occiput C 1234567 T 123456789101112 L 12345 Sac./Coccyx/Pelvis Posture Supports Supplements |
Exacerbated Same Improving Prognosis: Good Unable To Determine Guarded Poor Initials: |
| Date | Pain Tenderness Spasm Radiating Inflammation Par aesthesia Weakness Dec. R.O.M. Stiff/Tight |
Manipulation Neur.Mus.ReEd +Ortho. Test +Neuro. Test Deep Tis. Mass. Ultrasound Traction Heat Cryo Tx. Elect.Mus. Stim. |
Chronic/Acute Constant Frequent Intermittent Occasional Severe Moderate Slight Mild |
T.M.J. Occiput C 1234567 T 123456789101112 L 12345 Sac./Coccyx/Pelvis Posture Supports Supplements |
Exacerbated Same Improving Prognosis: Good Unable To Determine Guarded Poor Initials: |
| Date | Pain Tenderness Spasm Radiating Inflammation Par aesthesia Weakness Dec. R.O.M. Stiff/Tight |
Manipulation Neur.Mus.ReEd +Ortho. Test +Neuro. Test Deep Tis. Mass. Ultrasound Traction Heat Cryo Tx. Elect.Mus. Stim. |
Chronic/Acute Constant Frequent Intermittent Occasional Severe Moderate Slight Mild |
T.M.J. Occiput C 1234567 T 123456789101112 L 12345 Sac./Coccyx/Pelvis Posture Supports Supplements |
Exacerbated Same Improving Prognosis: Good Unable To Determine Guarded Poor Initials: |
| Date | Pain Tenderness Spasm Radiating Inflammation Par aesthesia Weakness Dec. R.O.M. Stiff/Tight |
Manipulation Neur.Mus.ReEd +Ortho. Test +Neuro. Test Deep Tis. Mass. Ultrasound Traction Heat Cryo Tx. Elect.Mus. Stim. |
Chronic/Acute Constant Frequent Intermittent Occasional Severe Moderate Slight Mild |
T.M.J. Occiput C 1234567 T 123456789101112 L 12345 Sac./Coccyx/Pelvis Posture Supports Supplements |
Exacerbated Same Improving Prognosis: Good Unable To Determine Guarded Poor Initials: |
| Date | Pain Tenderness Spasm Radiating Inflammation Par aesthesia Weakness Dec. R.O.M. Stiff/Tight |
Manipulation Neur.Mus.ReEd +Ortho. Test +Neuro. Test Deep Tis. Mass. Ultrasound Traction Heat Cryo Tx. Elect.Mus. Stim. |
Chronic/Acute Constant Frequent Intermittent Occasional Severe Moderate Slight Mild |
T.M.J. Occiput C 1234567 T 123456789101112 L 12345 Sac./Coccyx/Pelvis Posture Supports Supplements |
Exacerbated Same Improving Prognosis: Good Unable To Determine Guarded Poor Initials: |
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