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Chiropractic Re-Exam Note Template
A chiropractic re-exam note compares the patient’s findings and outcome scores with the initial exam, then decides whether to continue, taper, discharge, or refer. Copy the free template, see an improving case and a plateaued one, and check what goes in each section.
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- Two filled examples
Blank chiropractic re-exam note template
FreeCHIROPRACTIC RE-EXAM NOTE Patient: [Name] Date of birth: [Date] Date of re-exam: [Date] Initial exam: [Date of the initial exam] Care so far: [Number of visits over how many weeks] Chiropractor: [Name, credentials] INTERVAL HISTORY Patient's view: [How they feel compared with the start of care, in their words] Pain: [Rating out of 10 today, compared with the initial exam] Daily function: [What is easier now, and what is still limited] Adherence: [Visits attended, home exercises done, advice followed] New problems: [New complaints, neurological symptoms, red flags, or none] OUTCOME MEASURES Measure: [The named outcome measure used at the initial exam] Scores: [Initial score, today's score, and the change] Clinical meaning: [Whether the change is meaningful for this measure] RE-EXAMINATION Range of motion: [Initial and current values, by direction] Palpation and segments: [Current tenderness, tone, and restricted segments, compared with the initial exam] Orthopedic tests: [Each test repeated, with initial and current results] Neurological exam: [Repeated findings, and any change] GOAL STATUS Short-term goals: [Each goal: met, partly met, or not met] Long-term goals: [Each goal: met, partly met, or not met] ASSESSMENT Overall progress: [Improving, plateaued, or worse, with the evidence] Diagnosis: [Unchanged, revised, or new] Reasoning: [Why care should continue, change, taper, stop, or be referred] PLAN Decision: [Continue, taper, discharge, or refer] Visit frequency: [New frequency and duration, or none after discharge] Updated goals: [New or revised goals, with dates] Referral: [To whom, why, how urgent, and what was sent; or not needed] Self-management: [Home program, and when to come back] Next re-exam: [Date or visit number, or not applicable] Signed: [Chiropractor name, credentials, date and time]
Use it for
- Scheduled re-exams
- End of care plan
- Progress that stalls
- New or changed symptoms
- Planning a discharge
Two filled examples. Every part, filled in.
Each one follows the template. Use them to judge how much detail every part needs.
Chiropractic re-exam: low back pain at 6 weeks
Chiropractic clinic, scheduled re-exam, visit 10
Interval history
44-year-old woman, retail worker, re-examined 6 weeks after starting care for low back pain with left buttock pain; 10 visits so far. “Most days I forget about it.” Pain 2/10 today, 7/10 at the initial exam. Buttock pain gone for 3 weeks. Working full shifts; lifts stock up to 10 kg (22 lb) without pain, still careful with heavier boxes. Does her home exercises most days. No new symptoms; no numbness, weakness, or bladder or bowel changes.
Outcome measures
Oswestry Disability Index: 42% at the initial exam, 14% today: 28 points, or about 67% from the starting score. Well above the change usually considered meaningful.
Re-examination
Lumbar flexion 90%, pain-free; initial 50%, painful. Extension full; initial 60%, painful. Tenderness and tone at left L4-L5 now mild; initial marked. Mild restriction at L4-L5 only; initial L4-L5 and left sacroiliac joint. Kemp’s test negative on both sides; initial positive on the left, reproducing buttock pain. Straight-leg raise negative on both sides, unchanged. Strength, sensation, and reflexes normal, unchanged.
Goal status
Short-term goals: pain 4/10 or less, met; sitting 60 minutes, met; buttock pain resolved, met. Long-term goals: full shifts without pain, met; lifting 15 kg (33 lb) at work without pain, partly met, comfortable up to 10 kg (22 lb).
Assessment
Mechanical low back pain with lumbar segmental dysfunction, improving: meaningful change in pain, function, and examination. Diagnosis unchanged. The remaining goal is heavier lifting, best addressed with strengthening while visits are reduced.
Plan
Taper: weekly for 2 weeks, then every 2 weeks for 2 visits. Updated goal: lift 15 kg (33 lb) from floor to waist without pain within 4 weeks. Home program progressed: hip hinge practice with a light kettlebell and bird-dogs, 3 times a week. Planned discharge at 10 weeks, with a final Oswestry. Return sooner for new leg pain, numbness, or weakness.
Chiropractic re-exam: neck pain with no progress, referred
Chiropractic clinic, scheduled re-exam, visit 12
Interval history
57-year-old man, re-examined 6 weeks after starting care for neck pain with no injury; 12 visits so far. “It’s about the same.” Pain 5/10 today, 5/10 at the initial exam. Short relief after each visit, gone by the next day. Sleeping poorly, and worried his neck is “wearing out.” Does his exercises about twice a week. No arm pain, numbness, weakness, dizziness, or change in walking or hand use.
Outcome measures
Neck Disability Index: 36% at the initial exam, 32% today: 4 percentage points, or about 11% from the starting score. Below the change usually considered meaningful.
Re-examination
Cervical rotation 55° right and 60° left; initial 50° and 60°. Extension painful at end range, unchanged. Tenderness and tone in both upper trapezius muscles, unchanged; restriction at C5-C6 and C6-C7, unchanged. Spurling’s test negative on both sides, unchanged. Strength, sensation, and reflexes normal; Hoffmann’s sign negative; gait normal.
Goal status
Short-term goals: pain 3/10 or less, not met; rotation 70° both ways, not met. Long-term goals: sleeping through the night, not met; Neck Disability Index under 15%, not met.
Assessment
Chronic mechanical neck pain, plateaued after 6 weeks of care, with no meaningful change in pain, function, or examination. No red flags or neurological signs. Poor sleep and worry about his neck may be slowing recovery. Continuing the same care is unlikely to help.
Plan
Refer: letter to his family physician with the initial and re-exam findings and scores, asking for a medical review and whether other care, such as physical therapy with graded exercise, would help. Routine, not urgent. Chiropractic care paused until their review; open to co-managing if they agree. Discussed the plan and his worries; his exam shows no signs of nerve damage. Continue daily neck exercises and walking. Seek care sooner for arm numbness or weakness, or trouble walking or using his hands.
What goes in each part.
Interval history
The patient’s account of change since the initial exam, using the same pain and function questions you asked then.
- The patient’s view, in their words
- Pain now and at the initial exam
- What is easier, and what is still limited
- Attendance and home exercise adherence
- New symptoms or red flags
Avoid: Asking different questions than at the initial exam. Like-for-like answers make the comparison work.
Outcome measures
The same named measure you used at the initial exam, scored again, with the change and whether it matters.
- The measure’s name, such as the Oswestry or Neck Disability Index
- Initial score, today’s score, and the change
- Whether the change is clinically meaningful
Avoid: Reporting today’s score without the starting value.
Re-examination
The initial exam’s findings, repeated the same way, with both values side by side.
- Range of motion, initial and current
- Palpation and segmental findings
- Each orthopedic test, repeated
- Neurological findings, and any change
Avoid: Switching methods, such as degrees at the initial exam and percent of normal now. Use the same method both times.
Goal status
Each goal from the initial plan, marked met, partly met, or not met.
- Each short-term goal and its status
- Each long-term goal and its status
- The evidence behind each status
Avoid: Dropping goals that weren’t met. Unmet goals explain the decision that follows.
Assessment
Your judgment of progress, whether the diagnosis still fits, and why the plan should continue, change, or stop.
- Improving, plateaued, or worse, with the evidence
- Diagnosis unchanged, revised, or new
- Factors helping or slowing recovery
- The reason for your decision
Avoid: “Progressing well” without the scores and findings that show it.
Plan
The decision, and what happens next because of it.
- Continue, taper, discharge, or refer
- New visit frequency, or the discharge plan
- Updated goals with dates
- Referral details: to whom, why, and how urgent
- Home program, and when to return
Avoid: Keeping the same visit frequency after a plateau without saying why.
Common mistakes, and how to avoid them.
No side-by-side numbers
A reader shouldn’t have to open the initial exam to see what changed. Write the initial value next to each current one.
Calling any drop progress
Small changes in an outcome score can be measurement noise. Judge the change against the measure’s threshold for meaningful change, and say whether it was reached.
Treating through a plateau
When a re-exam shows no meaningful change, change the approach, refer, or discharge, and write down why. More of the same is hard to justify.
Ignoring yellow flags
Poor sleep, fear of movement, and worry about damage can stall recovery. Note them, address them, and include them in any referral.
Discharge with no plan
Record the final scores, the home program, and when to come back or seek care, so the patient knows what to do if symptoms return.
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Frequently asked questions.
How often should a chiropractor do a re-exam?
At the interval set in the plan of care, often every 4 to 6 weeks or after a set number of visits, and sooner if symptoms change, new symptoms appear, or progress stalls.
What should a re-exam compare with the initial exam?
The pain rating, function, the named outcome measure, range of motion, and the orthopedic and neurological tests, each with the initial and current values side by side.
What counts as a meaningful change on the Oswestry or Neck Disability Index?
Thresholds vary by study and patient group. A common rule of thumb is an improvement of about 30% from the starting score, or about 10 points on the Oswestry’s 0 to 100 scale. Weigh it against the patient’s own goals.
What should I do when a patient plateaus?
Recheck the diagnosis and red flags, look for factors such as poor sleep or fear of movement, and change the approach or refer. Document your reasoning and what you told the patient.
Is this chiropractic re-exam note template free?
Yes. Copy it, or download it as a Word or text file. No account needed.
More chiropractic templates, and guides.
Chiropractic SOAP note template
Visit note with segmental findings, adjustments by region and technique, and response to care.
Chiropractic initial exam template
New-patient exam with red flag screen, orthopedic and neuro tests, consent, and a plan with goals.
AI scribe for chiropractors
Initial assessments, return visits, and progress notes drafted from the visit.
Progress notes guide
How to show change over time, with examples and a checklist.
Common chiropractic diagnosis codes
The codes chiropractors use most, in one list.
Vero for chiropractic
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