New Condition Form
Name: ________________________________________________
□ Right handed
□ Left handed
What is the reason for the visit?
□ Ambidextrous
□ injury
□ pain
Where is the location of the symptoms? □ Right
Date: _____/_____/_________
Occupation: ___________________________________________
□ numbness
□ Left
DOB: _____/_____/________
□ mass
□ other: ______________________________________
Area of body: _________________________________________________
When did the problem begin? _____________________________________________________________________________________
How did the problem start? □ no specific injury □ car accident □ sports □ fall □ work related □ other _________________________
My pain is:
□ sharp □ dull □ stabbing □ burning □ throbbing □ aching □ other _______________________________________
My symptoms also include:
□ locking
□ weakness
□ catching
How severe are the symptoms?
□ swelling
□ clicking
□ mild
□ stiffness
□ numbness/tingling
□ other __________________________________
□ moderate
□ severe
□ disabling
My symptoms are made better with: □ rest □ heat □ ice □ therapy □ medications
My symptoms are made worse when:
□ on uneven surfaces
□ gripping/grasping
□ sitting
□ therapy
□ working
□ instability
□ standing
□ walking
□ overhead activities
□ splint
□ bending
□ reaching
□ other_________________________
□ twisting/turning
□ throwing
□ lifting
□ squatting
□ typing
□ other______________________________
How often do the symptoms occur? □ minimal □ intermittent □ constant □ when sleeping at night □ other____________________
Since the symptoms started, it is □ getting better □ getting worse □ unchanged
Which treatments have you tried? □ rest □ heat □ ice □ therapy □ medications □ injection □ splint □ surgery
□ other________________________
Patient signature: _______________________________
_________________________________________________________________________________________________________________
Office Use Only
Examination: (□ = Normal)
□ Constitutional (3) P:
R:
Ht:
Wt:
□ General appearance (development, nutrition, body habitus, deformities, grooming)
□ Cardiovascular (Peripheral pulse)
□ Lymphatic (Palpation of lymph nodes)
Neurological/Psychological
□ Coordination □ Reflexes □ Sensation □ Orientation □ Mood/affect
Musculoskeletal
□ Gait
- Inspection/palpation (alignment, tenderness, crepitus, swelling)
- Stability (laxity, subluxation, or dislocation)
Head/neck
Right UE
Spine/ribs/pelvis Left UE
Head/neck
Right UE
Spine/ribs/pelvis Left UE
Right LE
Left LE
- ROM (with or without pain)
Head/neck
Right UE
Spine/ribs/pelvis Left UE
Right LE
Left LE
- Strength (tone, weakness, atrophy)
Right LE
Left LE
Head/neck
Right UE
Spine/ribs/pelvis Left UE
Right LE
Left LE
Skin
-Inspection/palpation (scars, rashes, lesions)
Head/neck
Right UE
Spine/ribs/pelvis Left UE
Right LE
Left LE
X-ray: □ see report
Impression:
Plan:
Level (3 of 3)
History (CC +)
Exam
Decision
Time counseling
1
1 HPI
1 Element
SF
10 minutes
2
1 HPI + 1 ROS
6 Elements
SF
20 minutes
3
4 HPI, 2-9 ROS
1 PFSH
12 Elements
Low
30 minutes
M.D. signature: _______________________________________
4
4 HPI, 10+ ROS
3 PFSH
All (29 Elements)
Moderate
45 minutes
5
4 HPI, 10+ ROS
3 PFSH
All (29 Elements)
High
60 minutes
Date: ___________________