Review Intake Form
I have reviewed the patient’s intake form with the patient including the past medical
history, past surgical history, medications, allergies, social history, review of systems,
and family history. I have signed the form, and it is entered into the chart as addendum to
the progress note for this clinic visit.
Review of medical history
I have reviewed with the patient the past medical history, past surgical history,
medications, allergies, social history, family history, and review of systems. The patient
reports there are no changes in past medical history, past surgical history, medications,
allergies, social history, family history, and review of systems.
Normal examination for UE complaint
General: pleasant, in no apparent distress, breathing easily
Neurologic: alert, awake, oriented x3, Cranial Nerves II-XII intact
HEENT: oropharynx clear, PERRLA, extra-ocular eye movement intact
Chest: normal respirations, symmetric bilateral chest expansion, no respiratory difficulty
CV: easily palpable bilateral radial pulses, radial pulses equal and symmetric bilateral,
regular heart rate, easily palpable dorsalis pedis and posterior tibial pulses bilaterally
Abdomen: soft, non-tender to palpation, non-distended, benign
Pelvis: stable to AP and lateral compression
Cervical spine: non-tender to palpation, no pain with active and passive range of motion,
no palpable step-offs, negative spurlings sign, no evidence of muscle spasm, normal
cervical lordosis
Thoracolumbar spine: non-tender to palpation, no pain with active range of motion, no
palpable step-offs, no evidence of muscle spasm, normal thoracic kyphosis and lumbar
lordosis
Gait: normal
Lower extremities: 2+ deep tendon reflexes in the bilateral patellar and bilateral Achilles,
sensation intact throughout the bilateral lower extremities without deficits, 5/5 strength
throughout the bilateral lower extremities
Normal examination for LE complaint
General: pleasant, in no apparent distress, breathing easily
Neurologic: alert, awake, oriented x3, Cranial Nerves II-XII intact
HEENT: oropharynx clear, PERRLA, extra-ocular eye movement intact
Chest: normal respirations, symmetric bilateral chest expansion, no respiratory difficulty
CV: easily palpable bilateral radial pulses, radial pulses equal and symmetric bilateral,
heart rate regular, easily palpable dorsalis pedis and posterior tibial pulses bilaterally
Abdomen: soft, non-tender to palpation, non-distended, benign
Pelvis: stable to AP and lateral compression
Cervical spine: non-tender to palpation, no pain with active and passive range of motion,
no palpable step-offs, negative spurlings sign, no evidence of muscle spasm, normal
cervical lordosis
Thoracolumbar spine: non-tender to palpation, no pain with active range of motion, no
palpable step-offs, no evidence of muscle spasm, normal thoracic kyphosis and lumbar
lordosis, negative straight leg raise bilaterally
Upper extremities: 2+ deep tendon reflexes in the bilateral biceps/triceps/brachioradialis,
sensation intact throughout the bilateral upper extremities without deficits, 5/5 strength
throughout the bilateral upper extremities
Normal examination spine complaint
General: pleasant, in no apparent distress, breathing easily
Neurologic: alert, awake, oriented x3, Cranial Nerves II-XII intact
HEENT: oropharynx clear, PERRLA, extra-ocular eye movement intact
Chest: normal respirations, symmetric bilateral chest expansion, no respiratory difficulty
CV: easily palpable bilateral radial pulses, radial pulses equal and symmetric bilateral,
heart rate regular, easily palpable dorsalis pedis and posterior tibial pulses bilaterally
Abdomen: soft, non-tender to palpation, non-distended, benign
Pelvis: stable to AP and lateral compression
Upper extremities: 2+ deep tendon reflexes in the bilateral biceps/triceps/brachioradialis,
sensation intact throughout the bilateral upper extremities without deficits, 5/5 strength
throughout the bilateral upper extremities
Lower extremities: 2+ deep tendon reflexes in the bilateral patellar and bilateral Achilles,
sensation intact throughout the bilateral lower extremities without deficits, 5/5 strength
throughout the bilateral lower extremities
Normal preop examination
General: pleasant, no apparent distress, breathing easily
Neurologic: alert, awake, oriented x3, Cranial Nerves II-XII intact
HEENT: oropharynx clear, PERRLA, extra-ocular eye movement intact
Chest: normal respirations, symmetric bilateral chest expansion, lungs clear to
auscultation bilaterally, breath sounds equal bilaterally
Heart: regular rate and rhythm with no murmurs, rubs, or gallops
Abdomen: soft, non-tender to palpation, non-distended, benign
Pelvis: stable to AP and lateral compression
Cervical spine: non-tender to palpation, no pain with active and passive range of motion,
no palpable step-offs, negative spurlings sign, no evidence of muscle spasm, normal
cervical lordosis
Thoracolumbar spine: non-tender to palpation, no pain with active range of motion, no
palpable step-offs, no evidence of muscle spasm, normal thoracic kyphosis and lumbar
lordosis, negative straight leg raise bilaterally
Normal right shoulder
Right shoulder: skin intact, normal appearance of soft tissues, no sign of infection, full
active and passive range of motion, 5/5 strength of forward flexion, 5/5 strength of
extension, 5/5 strength of abduction, 5/5 strength of external rotation, 5/5 strength
internal rotation, no tenderness to palpation over the acromioclavicular joint, no
tenderness to palpation over the rotator cuff interval, negative impingement sign,
negative cross body adduction sign, negative sulcus sign, negative apprehension sign,
negative Speed's test, negative O'Brien's test, negative belly press, negative lift off test,
no evidence of scapular winging, no crepitus
Normal right upper extremity neurovascular exam
Right upper extremity: 2+ radial pulse, all fingers are warm and pink with brisk capillary
refill, the axillary/musculocutaneous/radial/ulnar/median/anterior interosseous/posterior
interosseous are intact both motor and sensory, arm and forearm compartments are soft
and compressible, no pain with passive stretch of digits, no sign of compartment
syndrome, sensation is intact throughout the entire right upper extremity to light touch
and sharp touch, strength is 5/5 throughout
Normal left shoulder
Left shoulder: skin intact, normal appearance of soft tissues, no sign of infection, full
active and passive range of motion, 5/5 strength of forward flexion, 5/5 strength of
extension, 5/5 strength of abduction, 5/5 strength of external rotation, 5/5 strength
internal rotation, no tenderness to palpation over the acromioclavicular joint, no
tenderness to palpation over the rotator cuff interval, negative impingement sign,
negative cross body adduction sign, negative sulcus sign, negative apprehension sign,
negative Speed's test, negative O'Brien's test, negative belly press, negative lift off test,
no evidence of scapular winging, no crepitus
Normal left upper extremity neurovascular exam:
Left upper extremity: 2+ radial pulse, all fingers are warm and pink with brisk capillary
refill, the axillary/musculocutaneous/radial/ulnar/median/anterior interosseous/posterior
interosseous are intact both motor and sensory, arm and forearm compartments are soft
and compressible, no pain with passive stretch of digits, no sign of compartment
syndrome, sensation is intact throughout the entire left upper extremity to light touch and
sharp touch, strength is 5/5 throughout
Normal Right elbow
Right elbow: skin intact, normal appearance of soft tissues, no sign of infection, full
active and passive range of motion, 5/5 strength of flexion and extension, no tenderness
over the epicondyles, no evidence of instability, no crepitus
Normal Left elbow
Left elbow: skin intact, normal appearance of soft tissues, no sign of infection, full active
and passive range of motion, 5/5 strength of flexion and extension, no tenderness over the
epicondyles, no evidence of instability, no crepitus
Normal right wrist
Right wrist: normal soft tissue examination, no sign of infection, no instability of carpus,
full active and passive range of motion, 5/5 strength of flexion/extension/radial
deviation/ulnar deviation
Normal left wrist
Left wrist: normal soft tissue examination, no sign of infection, no instability of carpus,
full active and passive range of motion, 5/5 strength of flexion/extension/radial
deviation/ulnar deviation
Normal right knee
Right knee: skin intact, no open wounds, full active and passive range of motion, no soft
tissue swelling, no joint effusion, no crepitus, negative anterior drawer examination,
negative Lachman's examination, negative posterior drawer examination, negative
McMurray's examination, stable to varus and valgus stress at 0 and 30 degrees, no
tenderness to palpation over the medial or lateral joint line
Normal Left knee
Left knee: skin intact, no open wounds, full active and passive range of motion, no soft
tissue swelling, no joint effusion, no crepitus, negative anterior drawer examination,
negative Lachman's examination, negative posterior drawer examination, negative
McMurray's examination, stable to varus and valgus stress at 0 and 30 degrees, no
tenderness to palpation over the medial or lateral joint line
Normal right hip
Right hip: full active and passive range of motion, no crepitus, no instability, 5/5 strength
in flexion/extension/abduction/adduction
Normal left hip
Left hip: full active and passive range of motion, no crepitus, no instability, 5/5 strength
in flexion/extension/abduction/adduction
Normal right ankle
Right ankle: normal soft tissue appearance, no crepitus with range of motion, negative
anterior drawer exam, no instability with varus and valgus stress, full active and passive
range of motion, no tenderness to palpation over the malleoli, 5/5 strength
flexion/extension/eversion/inversion
Normal left ankle
Left ankle: normal soft tissue appearance, no crepitus with range of motion, negative
anterior drawer exam, no instability with varus and valgus stress, full active and passive
range of motion, no tenderness to palpation over the malleoli, 5/5 strength
flexion/extension/eversion/inversion
Normal bilateral lower extremity neurovascular exam:
Lower extremities: 5/5 strength throughout the bilateral lower extremities, 2+ symmetric
deep tendon reflexes bilaterally in the patellar and achilles, sensation intact throughout
the bilateral lower extremities to light touch/sharp touch/vibratory sensation, down going
babinski bilaterally, no evidence of clonus bilaterally
Right shoulder steroid injection
I have verified the patient’s allergies. I have discussed with the patient their diagnosis,
prognosis, and options for treatment. I have explained the proposed treatment of
corticosteroid injection. The patient has verbalized an understanding of the procedure. I
have discussed the risks and possible benefits of the procedure with the patient in detail.
The patient has verbalized an understanding of the risks and possible benefits. The
patient's questions were answered to the patient's satisfaction. Verbal informed consent
was obtained.
The right shoulder was prepped and draped in standard sterile fashion using alcohol and
chlorhexadine. Using meticulous sterile technique a right shoulder subacromial injection
was performed. 9mL of 1% lidocaine and 1mL of kenalog (40mg/mL concentration) was
injected. A total dose of 40mg of kenalog was given. The patient tolerated the procedure
well. There were no known complications.
Left shoulder steroid injection
I have verified the patient’s allergies. I have discussed with the patient their diagnosis,
prognosis, and options for treatment. I have explained the proposed treatment of
corticosteroid injection. The patient has verbalized an understanding of the procedure. I
have discussed the risks and possible benefits of the procedure with the patient in detail.
The patient has verbalized an understanding of the risks and possible benefits. The
patient's questions were answered to the patient's satisfaction. Verbal informed consent
was obtained.
The left shoulder was prepped and draped in standard sterile fashion using alcohol and
chlorhexadine. Using meticulous sterile technique a left shoulder subacromial injection
was performed. 9mL of 1% lidocaine and 1mL of kenalog (40mg/mL concentration) was
injected. A total dose of 40mg of kenalog was given. The patient tolerated the procedure
well. There were no known complications.
Right knee steroid injection
I have verified the patient’s allergies. I have discussed with the patient their diagnosis,
prognosis, and options for treatment. I have explained the proposed treatment of
corticosteroid injection. The patient has verbalized an understanding of the procedure. I
have discussed the risks and possible benefits of the procedure with the patient in detail.
The patient has verbalized an understanding of the risks and possible benefits. The
patient's questions were answered to the patient's satisfaction. Verbal informed consent
was obtained.
The right knee was prepped and draped in standard sterile fashion using alcohol and
chlorhexadine. Using meticulous sterile technique a right knee intra-articular injection
was performed via the superior lateral portal. 9mL of 1% lidocaine and 1mL of kenalog
(40mg/mL concentration) was injected. A total dose of 40mg of kenalog was given. The
patient tolerated the procedure well. There were no known complications.
Left knee steroid injection
I have verified the patient’s allergies. I have discussed with the patient their diagnosis,
prognosis, and options for treatment. I have explained the proposed treatment of
corticosteroid injection. The patient has verbalized an understanding of the procedure. I
have discussed the risks and possible benefits of the procedure with the patient in detail.
The patient has verbalized an understanding of the risks and possible benefits. The
patient's questions were answered to the patient's satisfaction. Verbal informed consent
was obtained.
The left knee was prepped and draped in standard sterile fashion using alcohol and
chlorhexadine. Using meticulous sterile technique a left knee intra-articular injection was
performed via the superior lateral portal. 9mL of 1% lidocaine and 1mL of kenalog
(40mg/mL concentration) was injected. A total dose of 40mg of kenalog was given. The
patient tolerated the procedure well. There were no known complications.