Follow Up - Intake-new

Last Name

Body parts evaluated:NeckMid-backLow-backShoulder
Last Name

/10 Constant Intermittent Sharp Electric_Shooting Throbbing Pulsating Dull AchyKneeNeckThe patient reportedDuring thatNoneDOS:FOLLOW-UPIntegrative Spine & Sports
First Name
First Name
First Name
DOS
DOA:
Sex: F M
Knee Others:
Coveredbodyparts
Coveredbodyparts
Degree of Disability:
None

Degree of Disability:255075100
Work Status

Able to go back to workWorkingNot WorkingPartially Working The
Patient is s/p
Patient is s/p
Patient is s/p
Patient is s/p
The patient reported

LowbackHow would youdescribe your pain?Patient’s symptoms have /have not returned to baseline. Pt. is doing PT/Chiro /Acupuncture times /weekThere was functional improvement in his/her ROMRadicular symptoms had improved by greater than% symptoms improvement that lasted a period ofdays/weeks.
days/weeks period patient reported:
There was functional improvement in his/her ROM
Neck

/10 Constant Intermittent Sharp Electric _Shooting Throbbing Pulsating Dull AchyShoulder/10Midbackdays/weeks period patient reported:If yes, where and what is their current occupation?Knee Others:Sex: F MDOA:
/10
Midback

IntermittentSharpElectThrobbing/10
/10
Intermittent

ConstantIntermittentSharpElectric_ShootingThrobbingPulsatingDullAchyConstantric _ShootingPulsatingDull/10 Constant Intermittent Sharp Electric _Shooting Throbbing Pulsating Dull AchyAchy
Lowback
/10 Constant Intermittent Sharp Electric _Shooting Throbbing Pulsating Dull Achy
Knee
Neckradiates to L / R arm forearm hand wrist withnumbness tinglingto arm forearm hand wristLow backradiates to L / R hip thigh knee leg ankle foot withnumbness tinglingto hip thigh knee leg ankle foot
Neckradiates to L / R arm forearm hand wrist withnumbness tinglingto arm forearm hand wristLow backradiates to L / R hip thigh knee leg ankle foot withnumbness tinglingto hip thigh knee leg ankle foot
On examination the patient has taut, tender bands in the
Gait
Range of Motion(For Reference - normal values in brackets)
Neck:FF(60)
Ext(50)
Rot.(80)L
R
Mid-back: (Mildly Moderately Severely) Decreased
Low-back:FF(90)
Ext(40)
Rot.(60)L
R
Shoulder:Abd(180)L
R
Flex(180)L
R
Ext Rot
(90)L
R
Int Rot(90)L
R
R
Knee:Flex(135)L
R
Exten(0)L
R
Others
Allergies
Medications taken
Other providers being seen (example: ortho, spine, psychologist, psychiatrist, neurologist, etc)
RECOMMENDATIONS

EpidurogramDiscogramSI Fusion :
Request/Schedule:
SCS Implant

MRIEMG/NCVEpiduralSI InjectionRequest/Schedule:SCS TrialDiscectomy
SI Fusion
Rx Prescription / Refill
Referral:(Chiro,PT,spine,ortho,psychologist,psychiatrist,neurologist,etc)
The following are consequential to the case
DOA
accident and should be amended to his
(list the body parts)
DME Dispensed at today's office visit

- L0637 LSO Back Brace- E0730 Tens Unit- E0731 Conductive garment (neck, back, wrist, knee)- L1832- OA Hinged Knee Brace- L1843- OA Knee Brace- L1971 - Ankle Brace- L1902 - Ankle Brace- L3807 - Thumb Spika- L3908 - Wrist Brace- L3916 - Wrist Brace- L0456 - TLSO Back Brace- L0480 - TLSO Back Brace- E0762 - Transcutaneous electronic joint stim, includes all accessories
DME Meadowbrook Medical Supplies (other provider) -- please see attached sheet for your reference

- T5001 - Ortho Positioning Seat- E0855 - Cervical Traction Unit
Follow Up visit
NOTES
Should be Empty:

DOA:

Knee Others:

Degree of Disability:

Gait

Ext Rot

Request/Schedule:

Referral:(Chiro,PT,spine,ortho,psychologist,psychiatrist,neurologist,etc)

DOA