Privileging - Chiropractor
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Check the boxes next to the privileges you seek.
History and phyical examination
Orthopedic Testing
Soft Tissue Palpation
Medical record review
Range of motion
Joint palpation
Neurological Testing
Postural Examination
Vital signs
X-ray
Advanced imaging
Laboratory studies
Electrodiagnostic Studies
Patient Education
Exercise
Physical Modalities
Acupressure
Acupuncture
Massage
Orthoses
Nutritional supplements
Homeopathy
Spinal Manipulation
Medical translation (enter language)
Any additional privileges not listed here?
Comments/concerns:
I attest that I have appropriate training, competence, experience, and comfort level for each privilege requested.
Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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