Chiropractic New Patient Form

Patient Name: [ J.J Intern:[Alex File Number:[ Date:[27 April 2021

Vital Signs - Good

Pulse: 70 min Resp: 18 /min Temp: 36.5 BP 123 / 84

Introduction / Complaint Summary

Lower back and right hip pain. patient pointed to

area where it was located where the patient was
point it was refering to more so over the right
SIJ . This pain happens when going from a being
over position to a standing position.
Special Care Hasn't seen anyone for this issue,
as it has really bother him yet.

Chief Complaint
1. Location Lower Back Pain and Right SIJ pain
2. Onset On and off over the last month
3. Duration Pain stays around for about an hour after physical activity and heavy lift requirements at work
4. Course Pain doesn't travel and it is till in the general lower back area
5. Type Sharp pain in the being and then it gradual reduces to a dull pain
6. Radiating No radiation
7.Relieving Factors [Sitting and laying down reduces the stress
8. Aggravating Factors Picking heavy objects off the ground and standing for a long period of time
9. Previous Episode No, only started about a month ago
10. Previous Management N/A
11. Associated Symptoms N/A
Medical History Surgies to the planter surfers of the foot, for planter fascities to
Illnesses / Surgeries / increase the arching in the right surfers of the foot.
Medications / Accidents
Family History Cardiovascular conditions - high blood pressure mothers side of the family, and hearter attacks.
Psycho-social History Small amount of stress from a combination of work, uni and home life/
Systems Review Gastrointenal promblems - has an introlance to dairy
Occupation Sales assistant at bfc
Patient's Treatment Goals Reduce the pain, and reduce the amount of time it is occuring.

Differential Diagnosis 1. Sacroiliac Sprain and Subluxation or 2. Lumbar Sprain and Subluxation

Intern Signature A.P Date 27/04/2021

[ Comments

Supervisor Signature Date [

[ Comments

Observation Findings
Gait knee rotate inwards when walking
resulting the feet to follow the same
direction, when taking a stride the leg
does a extra movement to bring back
to neutral. reduced arm swing on right

Postural Analysis Vaglus at the knees causing ankles to

invert, and resulting with toe point outwards.
reduced archs in both feet. Arm carriage is
long on the right due to the rolling of the
right should.

General Poor posture when

deminstating how he
would pick up the
heavy objects at work,
how he sits to
temporary relief the
pain. leg length
difference longer on
the right.

Examination
o✔ Ortho [ When performing SLR was negative but resulting in more of a stretching pain.
✔
o Range of Motion A/P/R [ Range of motion reduced to the right at L4-5 and PI to the right. Tender to
o✔ Palpation [ palpate over the right SIJ up to about L2. Neuro exam was completed but nosigns
o✔ Neuro [ of reduced senativite.
Region -ve +ve
TMJ [ ]
Cervical [ ]
Thoracic [ ]
Lumbar [ Kemps, SLR & Braggards [ ]
SIJ [ ] [ ] SIJ Compression, Distraction. Belts, Marching.
Hip [ ] Hibb's, Yeomans, Ely's & FABER [ ]
Knee [ ] [ ]
Ankle [ ] [ ]
Shoulder [ ] [ ]
Elbow [ ] [ ]
Wrist/Hand [ ] [ ]
Other [ ] [ ]

Special Chiro Tests [ ] [ ] Leg length - longer on the right

Neurological Testing [ ] CN assessment of lower limbs [ ]
Systems Examination [ ] [ ]
Imaging [ ] [ ]
Laboratory / Other [ ] [ ]
Intern Signature [ A.P Date [ 27/04/2021
Comments [

Supervisor Signature Date [

[ Comments [