CHIROPRACTIC INITIAL EXAM

Patient: [Name]
Date of birth: [Date]
Date of exam: [Date]
Referred by: [Self, physician, or other]
Occupation and activities: [Job demands, sport, hobbies]
Chiropractor: [Name, credentials]

HISTORY
Chief complaint: [Main problem and region, in the patient's words]
Onset: [When it began, and the mechanism: injury, overuse, or no clear cause]
Symptoms: [Quality, rating out of 10 now and at worst, radiation, numbness or tingling]
Pattern: [What aggravates and eases it, and how it changes through the day]
Previous episodes: [Past episodes, imaging, care received, and how it helped]
Health history: [Conditions, surgeries, fractures, osteoporosis, blood thinners, current medications]
Functional limits: [Work, sleep, exercise, daily tasks; baseline outcome measure score]
Patient goals: [What the patient wants to be able to do again]

RED FLAG SCREEN
Serious conditions: [Cancer history, unexplained weight loss, fever, constant night pain, recent trauma, long-term steroid use]
Nerve compromise: [Saddle numbness, bladder or bowel changes, progressive weakness, unsteady gait]
Neck and head: [Dizziness, double vision, slurred speech, trouble swallowing, drop attacks, sudden severe headache]
Outcome: [No red flags, or the finding and what was done]

EXAMINATION
Vital signs: [BP, pulse, height, weight]
Observation: [Posture, gait, muscle wasting, swelling]
Active range of motion: [Each direction in degrees or percent of normal, with pain]
Palpation: [Tenderness, muscle tone, trigger points, by side and level]
Motion palpation: [Fixated or hypomobile segments and joints]
Orthopedic tests: [Name, side, and result of each test]
Neurological exam: [Dermatomes, myotomes, reflexes, upper motor neuron signs]

IMAGING
Indication: [Imaging indicated or not, and the reason]
Prior imaging: [Studies and reports reviewed, or none]

DIAGNOSIS
Working diagnosis: [Diagnosis by region, with the findings that support it]
Differential: [Other causes considered, and why they are less likely]
Prognosis: [Expected course, and factors that may slow recovery]

INFORMED CONSENT
Explained: [Proposed care, common and rare material risks, expected benefits, and alternatives, including no care]
Agreement: [Questions answered, and verbal or written consent given]

TREATMENT PLAN
Today's treatment: [Adjustments by region and technique, other therapies]
Frequency: [Visits per week and number of weeks]
Short-term goals: [Measurable goals for the next 2 to 4 weeks]
Long-term goals: [Functional goals for the end of the plan]
Self-care: [Exercises, activity changes, workstation or sport advice]
Re-exam: [Date or visit number of the first re-exam]
Co-management: [Referrals or other clinicians involved, or none]

Signed: [Chiropractor name, credentials, date and time]