LUMBOSACRAL SPINE T-SHEET
CC:
LS Spine Pain R 
HPI:
Onset:
Mechanism of injury:
Location:
Radiation:
Exacerbating factors:
Relieving factors:
L 
Yes 
ROS:
Fever  Chills 
Weakness  Night Pain 
PMHx:
Meds:
Allergies:
Chronic medical conditions:
Immunizations Current:
No 
Where:
Numbness  Paresthesias 
Weight Loss 
Amount_________
Yes  No 
Soc Hx:
Occupation and/or Activities:
Smoking status: Current  Past  Never 
IV Drug Use:
Yes  No 
PE:
Vital Signs:
BP:
P:
General Appearance:
Gait:
Normal  Limp 
Skin:
Redness
Yes 
Warmth
Yes 
Ecchymosis Yes 
Deformity
Yes 
Ulcers
Yes 
Distal Hair pattern:
Wt:
BMI:
RR:
Assist  _________________ Unable to bear weight 
No 
Location:
No 
Location:
No 
Location:
No 
Location:
No 
Location:
Normal 
Decreased 
Right
Left
Vascular:
Dorsalis Pedis Pulse: Nl    Absent  Nl    Absent 
Post Tibialis Pulse: Nl    Absent  Nl    Absent 
Capillary Refill:
Normal  Slow 
Normal  Slow 
Nl  Abnormal 
Nl  Abnormal 
Neuro:
Straight Leg Raise:
Toe Raise:
Nl  Abnormal 
Nl  Abnormal 
Walk on Toes:
Nl  Abnormal 
Nl  Abnormal 
Walk on Heels:
Nl  Abnormal 
Nl  Abnormal 
Knee Jerk Reflex: Nl    Absent  Nl    Absent 
Ankle Jerk Reflex: Nl    Absent  Nl    Absent 
Distal Sensation: Nl    Absent  Nl    Absent 
ROM:
Flexion: Nl    Painful 
Nl    Painful 
Extension: Nl    Painful 
Nl    Painful 
Nl  Abnormal 
Nl  Abnormal 
Active Eval:
Lachman (ACL):
McMurray (Med meniscus):
Nl  Abnormal 
Nl  Abnormal 
Soft Tissue:
Vertebral Tenderness:
Yes  No 
Yes  No 
(Palpation)
TREAT APPROPRIATELY
TREAT WITH CLOSE
FOLLOW-UP
Mechanical Back Pain ..................................................... 724.2
Lumbar degenerative disc disease................................ 722.52
Disc herniation ................................................................ 722.2
Low Back Pain ................................................................. 724.2
Lumbar radiculopathy ..................................................... 724.4
Lumbar sprain/strain ...................................................... 846.0
SI Joint strain ................................................................... 846.1
Nonspecific low back pain with negative evaluation...... 724.2
Spinal stenosis with mild symptoms ............................. 724.02
Atypical pain with negative findings
(< 1 week f/u)
CALL CONSULTANT
THAT DAY
CONSULT
OR
REFER
Severe symptoms
Cauda equine
Significant motor symptoms
Failure of conservative therapy
Abnormal x-ray findings
Spinal stenosis (severe or not responding to conservative management)
Plan:
 Xray / Imaging
 Laboratory Eval
 NSAIDs
 Acetaminophen
 Other
 PRICE Protocol
 Physical Therapy
Disposition:
 Treatment initiated: Follow-up __________ weeks
 Treatment / Work up Initiated: Follow-up ≤ 1 week __________ days
 Immediate call to Dr.
 Consultation initiated with Dr.
 Referral to Dr.