<?xml version="1.0" encoding="UTF-8"?> <!DOCTYPE abiword PUBLIC "-//ABISOURCE//DTD AWML 1.0 Strict//EN" "http://www.abi source.com/awml.dtd"> <abiword template="false" xmlns:fo="http://www.w3.

org/1999/XSL/Format" xmlns:mat h="http://www.w3.org/1998/Math/MathML" xid-max="72" xmlns:dc="http://purl.org/dc /elements/1.1/" fileformat="1.1" xmlns:svg="http://www.w3.org/2000/svg" xmlns:aw ml="http://www.abisource.com/awml.dtd" xmlns="http://www.abisource.com/awml.dtd" xmlns:xlink="http://www.w3.org/1999/xlink" version="2.6.8" xml:space="preserve" props="dom-dir:ltr; document-footnote-restart-section:0; document-endnote-type: numeric; document-endnote-place-enddoc:1; document-endnote-initial:1; lang:en-US ; document-endnote-restart-section:0; document-footnote-restart-page:0; document -footnote-type:numeric; document-footnote-initial:1; document-endnote-place-ends ection:0"> <!-- ======================================================================== -> <!-- This file is an AbiWord document. -> <!-- AbiWord is a free, Open Source word processor. -> <!-- More information about AbiWord is available at http://www.abisource.com/ -> <!-- You should not edit this file by hand. -> <!-- ======================================================================== -> <metadata> <m key="dc.date">2002-04-02T02:35:00Z</m> <m key="abiword.date_last_changed">2002-04-02T02:35:00Z</m> <m key="dc.creator">Win95</m> <m key="abiword.generator">AbiWord</m> <m key="dc.publisher"> </m> <m key="dc.format">application/x-abiword</m> <m key="dc.title">SUBJECTIVE COMPLAINTS</m> </metadata> <history version="5" edit-time="11987" last-saved="1326805153" uid="ab65aa1c-b7d 5-11df-85bb-a616392fc95f"> <version id="1" started="1283581130" uid="48fdce6a-b7ec-11df-85bb-a616392fc95f" auto="0" top-xid="65"/> <version id="2" started="1283649591" uid="aea4294a-b88b-11df-9d74-f5532ed7f7c5" auto="0" top-xid="66"/> <version id="3" started="1283700477" uid="28fe1e28-b902-11df-8274-e287a8c04984" auto="0" top-xid="67"/> <version id="4" started="1326138862" uid="b9ef21a8-3afb-11e1-87b3-c3a2aef4647c" auto="0" top-xid="68"/> <version id="5" started="1326805153" uid="0e4ae3a8-410b-11e1-8efc-a1f255339a70" auto="0" top-xid="72"/> </history> <styles> <s type="P" name="Heading 1" basedon="Normal" followedby="Normal" props="font-fa mily:Times New Roman; font-size:10pt; dom-dir:ltr; margin-bottom:3pt; lang:en-US ; font-weight:bold; line-height:1.0; text-align:left; margin-top:22pt; keep-with -next:yes"/> <s type="P" name="Normal" followedby="Normal" props="text-indent:0in; margin-top :0pt; margin-left:0pt; font-stretch:normal; line-height:1.0; text-align:left; fo nt-variant:normal; lang:en-US; dom-dir:ltr; margin-bottom:0pt; text-decoration:n one; font-weight:normal; bgcolor:transparent; color:000000; text-position:normal ; font-size:10pt; margin-right:0pt; font-style:normal; widows:2; font-family:Tim es New Roman"/> <s type="P" name="Footer" basedon="Normal" followedby="Footer" props="font-famil

y:Times New Roman; font-size:10pt; tabstops:3.0000in/C,6.0000in/C; dom-dir:ltr; lang:en-US; line-height:1.0; text-align:left"/> <s type="P" name="Body Text" basedon="Normal" followedby="Body Text" props="text -align:left; lang:en-US; font-size:9pt; line-height:1.0; font-family:Times New R oman; dom-dir:ltr"/> <s type="P" name="Header" basedon="Normal" followedby="Header" props="font-famil y:Times New Roman; font-size:10pt; tabstops:3.0000in/C,6.0000in/C; dom-dir:ltr; lang:en-US; line-height:1.0; text-align:left"/> <s type="C" name="Reference" props="font-size:10pt"/> <s type="P" name="Heading 2" basedon="Normal" followedby="Normal" props="font-fa mily:Times New Roman; font-size:9pt; dom-dir:ltr; margin-bottom:3pt; lang:en-US; font-weight:bold; line-height:1.0; text-align:left; margin-top:22pt; keep-withnext:yes"/> <s type="P" name="Heading 3" basedon="Normal" followedby="Normal" props="font-fa mily:Times New Roman; margin-top:22pt; font-style:italic; dom-dir:ltr; lang:en-U S; font-weight:bold; text-align:left; keep-with-next:yes; margin-bottom:3pt; lin e-height:1.0; font-size:9pt"/> </styles> <lists> <l id="1000" parentid="0" type="0" start-value="1" list-delim="%L" list-decimal= "."/> <l id="1001" parentid="0" type="0" start-value="2" list-delim="%L" list-decimal= "."/> </lists> <pagesize pagetype="Letter" orientation="portrait" width="8.500000" height="11.0 00000" units="in" page-scale="1.000000"/> <section footer="9" xid="21" props="page-margin-right:0.5000in; section-restartvalue:1; page-margin-header:0.5000in; page-margin-left:0.5000in; page-margin-foo ter:0.2799in; dom-dir:ltr; section-space-after:0.0000in; page-margin-top:0.5000i n; page-margin-bottom:0.6229in"> <p style="Heading 1" xid="22" props="text-align:left; keep-with-next:yes; line-h eight:1.0; dom-dir:ltr"><c props="font-weight:bold; font-size:8pt"></c><c props= "lang:en-US; font-size:8pt; font-family:Times New Roman; font-weight:bold">Date: ____/____/_______ Patient's Name_____ ______________________________________________ </c></p> <p style="Normal" xid="24" props="text-align:left; line-height:1.0; dom-dir:ltr" ><c props="lang:en-US; font-weight:bold; font-family:Times New Roman; font-size: 8pt; font-style:italic">SUBJECTIVE COMPLAINTS</c><c props="lang:en-US; font-weig ht:bold; font-family:Times New Roman; font-size:8pt; font-style:italic"></c></p> <p style="Normal" xid="25" props="text-align:left; line-height:1.0; dom-dir:ltr" ><c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font-weight:b old">The patient entered the office reporting that, in general, their overall co ndition has: </c><c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font-weight:bold"></c><c props="font-size:8pt">Improved-----No Change---- Worsened </c></p> <p style="Normal" xid="26" props="text-align:left; line-height:1.0; dom-dir:ltr" ><c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font-weight:b old">since their last office visit. Complaints today include the following: </c><c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font-weig ht:bold"></c><c props="font-size:8pt">Pain Level</c></p> <p style="Normal" xid="27" props="text-align:left; line-height:1.0; dom-dir:ltr" ><c props="font-family:Times New Roman; text-decoration:none; color:000000; font -size:8pt; text-position:normal; font-weight:bold; font-style:normal; lang:en-US ">HEADACHE:</c><c props="font-family:Times New Roman; text-decoration:none; colo r:000000; font-size:8pt; text-position:normal; font-weight:bold; font-style:norm al; lang:en-US"></c><c props="lang:en-US; font-size:8pt; font-family:Times New R oman; font-weight:bold"> Occipital Frontal Temporal Global L / R Minimal Mild Moderate Severe ____</c></ p>

<p style="Normal" xid="14" props="text-align:left; font-weight:bold; dom-dir:ltr ; line-height:1.0"><c props="lang:en-US; font-size:8pt; font-family:Times New Ro man; font-weight:bold"></c></p> <p style="Normal" xid="11" props="text-align:left; font-weight:bold; dom-dir:ltr ; line-height:1.0"><c props="lang:en-US; font-size:8pt; font-family:Times New Ro man; font-weight:bold"></c><c props="lang:en-US; font-size:8pt; font-family:Time s New Roman; font-weight:bold">NECK: Pain Stiffness Par esthesia Spasm L / R Minimal Mild Moderate Seve re ____</c></p> <p style="Normal" xid="66" props="text-align:left; font-weight:bold; dom-dir:ltr ; line-height:1.0"><c props="lang:en-US; font-size:8pt; font-family:Times New Ro man; font-weight:bold"></c></p> <p style="Normal" xid="28" props="text-align:left; font-weight:bold; dom-dir:ltr ; line-height:1.5"><c props="lang:en-US; font-size:8pt; font-family:Times New Ro man; font-weight:bold">UPPER BACK: Pain Stiffness Paresthesia Spas m L / R Minimal Mild Moderate Severe ____</c><c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font-w eight:bold"></c></p> <p style="Normal" xid="29" props="text-align:left; font-weight:bold; dom-dir:ltr ; line-height:1.5"><c props="lang:en-US; font-size:8pt; font-family:Times New Ro man; font-weight:bold">MIDBACK: Pain Stiffness Paresthesia S pasm L / R Minimal Mild Moderate Severe ____</c><c props="lang:en-US; font-size:8pt; font-family:Times New Roman; fon t-weight:bold"></c></p> <p style="Normal" xid="30" props="text-align:left; font-weight:bold; dom-dir:ltr ; line-height:1.5"><c props="lang:en-US; font-size:8pt; font-family:Times New Ro man; font-weight:bold">LOWBACK: Pain Stiffness Paresthesia Spasm L / R Minimal Mild Moderate Severe ____</ c><c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font-weight: bold"></c></p> <p style="Normal" xid="31" props="text-align:left; font-weight:bold; dom-dir:ltr ; line-height:1.5"><c props="lang:en-US; font-size:8pt; font-family:Times New Ro man; font-weight:bold">UPPER EXTR: Pain Stiffness Paresthesia Sp asm L / R Minimal Mild Moderate Severe ____</c><c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font -weight:bold"></c></p> <p style="Normal" xid="32" props="text-align:left; font-weight:bold; dom-dir:ltr ; line-height:1.5"><c props="lang:en-US; font-size:8pt; font-family:Times New Ro man; font-weight:bold">LOWER EXTR: Pain Stiffness Paresthesia Sp asm L / R Minimal Mild Moderate Severe ____</c><c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font -weight:bold"></c></p> <p style="Normal" xid="33" props="text-align:left; line-height:1.0; dom-dir:ltr" ><c props="lang:en-US; font-weight:bold; font-size:8pt"> Shoulder__Elbow__Wris t__Fingers____Hip____Knee____Ankle___Toes____ Notes:_______________________</c> <c props="lang:en-US; font-weight:bold; font-size:8pt"></c></p> <p style="Normal" xid="1" props="text-align:left; line-height:1.0; dom-dir:ltr"> <c props="lang:en-US; font-weight:bold; font-size:8pt">_________________________ _____________________________________________________________________</c><c prop s="lang:en-US; font-weight:bold; font-size:8pt"></c></p> <p style="Normal" xid="2" props="text-align:left; line-height:1.0; dom-dir:ltr"> <c props="lang:en-US; font-weight:bold; font-family:Times New Roman; font-size:8 pt; font-style:italic"></c><c props="lang:en-US; font-weight:bold; font-family:T imes New Roman; font-size:8pt; font-style:italic">OBJECTIVE / EXAMINATION</c></p > <p style="Normal" xid="34" props="text-align:left; line-height:1.0; dom-dir:ltr" ><c props="lang:en-US; font-weight:bold; text-decoration:underline; font-family: Times New Roman; font-size:8pt; font-style:italic">Muscle / Myofascial Hypertoni city</c><c props="lang:en-US; font-weight:bold; text-decoration:underline; fontfamily:Times New Roman; font-size:8pt; font-style:italic"></c><c props="lang:en-

US; font-size:8pt; font-family:Times New Roman; font-weight:bold"> was present i n the following paraspinal regions with the following degree of intensity.</c></ p> <p style="Normal" xid="35" props="text-align:left; line-height:1.0; dom-dir:ltr" ><c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font-weight:b old; font-style:italic"> </c><c props="lang:en-US; font-size:8pt; font-fami ly:Times New Roman; font-weight:bold; font-style:italic"></c><c props="lang:en-U S; font-weight:bold; font-family:Times New Roman; font-size:8pt; font-style:ital ic"> (Key: 1 = Minimal, 2 = Mild, 3 = Mild to Moderate, 4 = Moderate, 5 = Moder ate to Severe, 6 = Severe)</c></p> <p style="Normal" xid="36" props="text-align:left; line-height:1.0; dom-dir:ltr" ><c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font-weight:b old">CERVICAL</c><c props="lang:en-US; font-size:8pt; font-family:Times New Roma n; font-weight:bold"></c><c props="lang:en-US; font-weight:bold; font-family:Tim es New Roman; font-size:8pt; font-style:italic"> </c><c props="la ng:en-US; font-size:8pt; font-family:Times New Roman; font-weight:bold">__L / __ R Suboccipital __L / __ R Mid Cervical __L / __ R Upper Trapezius</c></p> <p style="Normal" xid="67" props="text-align:left; line-height:1.0; dom-dir:ltr" ><c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font-weight:b old"></c></p> <p style="Normal" xid="37" props="text-align:left; line-height:1.5; dom-dir:ltr" ><c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font-weight:b old">THORACIC</c><c props="lang:en-US; font-size:8pt; font-family:Times New Roma n; font-weight:bold"></c><c props="font-size:8pt"> __L / __ R Para spinal __L / __ R Mid Scapular __L / __ R Lower Trapez ius</c></p> <p style="Normal" xid="9" props="text-align:left; line-height:1.5; dom-dir:ltr"> <c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font-weight:bo ld"></c><c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font-w eight:bold">LUMBOSACRAL __L / __ R Upper Paraspinal __L / _ _ R Lower Paraspinal __L / __ R Piriformis / Psoas</c></p> <p style="Normal" xid="38" props="text-align:left; line-height:1.0; dom-dir:ltr" ><c props="lang:en-US; font-weight:bold; text-decoration:underline; font-family: Times New Roman; font-size:8pt; font-style:italic">Range of Motion</c><c props=" lang:en-US; font-weight:bold; text-decoration:underline; font-family:Times New R oman; font-size:8pt; font-style:italic"></c><c props="lang:en-US; font-weight:bo ld; font-family:Times New Roman; font-size:8pt; font-style:italic">, </c><c prop s="lang:en-US; font-size:8pt; font-family:Times New Roman; font-weight:bold">was evaluated with the following findings: ___Global ___Segmental ___Both</c></p> <p style="Normal" xid="39" props="text-align:left; line-height:1.5; dom-dir:ltr" ><c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font-weight:b old"> </c><c props="lang:en-US; font-size:8pt; font-family:Times New Roma n; font-weight:bold"></c><c props="font-size:8pt">(</c><c props="lang:en-US; fon t-weight:bold; font-family:Times New Roman; font-size:8pt; font-style:italic"> L evel of Restriction Key: 1 = Minimal, 2 = Mild, 3 = Mild to Moderate, 4 = Moder ate, 5 = Moderate to Severe, 6 = Severe</c><c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font-weight:bold">)</c></p> <p style="Normal" xid="40" props="text-align:left; text-indent:0.2500in; line-he ight:1.5; dom-dir:ltr"><c props="lang:en-US; font-size:8pt; font-family:Times Ne w Roman; font-weight:bold">Cervical :</c><c props="lang:en-US; font-size:8pt; fo nt-family:Times New Roman; font-weight:bold"></c><c props="font-size:8pt"> ___L / ___R Thoracic: ___L / ___R Lumbar: ___L / ___R Extremity.______ ______: ___L / ___R </c></p> <p style="Normal" xid="41" props="text-align:left; line-height:1.5; dom-dir:ltr" ><c props="lang:en-US; font-weight:bold; font-family:Times New Roman; font-size: 8pt; font-style:italic">ASSESSMENT / ACTION ____________ ___L / ___R</c><c props="lang:en-US; font-weight:bold; f

ont-family:Times New Roman; font-size:8pt; font-style:italic"></c></p> <p style="Normal" xid="42" props="text-align:left; line-height:1.5; dom-dir:ltr" ><c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font-weight:b old">___ Patient is improved</c><c props="lang:en-US; font-size:8pt; font-family :Times New Roman; font-weight:bold"></c><c props="font-size:8pt"> ___ Pati ent is unchanged ___ Patient is worsened ____Exacerbation ______New injury</c></p> <p style="Normal" xid="43" props="text-align:left; tabstops:0.0000in/L; line-hei ght:1.5; dom-dir:ltr; margin-left:-0.2500in"><c props="lang:en-US; font-weight:b old; font-family:Times New Roman; font-size:8pt; font-style:italic"> Joint misalignments / Fixations </c><c props="lang:en-US; font-weight:bold; font-fam ily:Times New Roman; font-size:8pt; font-style:italic"></c><c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font-weight:bold">were detected in the following areas:----- Misalignment/fixations adjusted without incident</c></ p> <p style="Normal" xid="44" props="text-align:left; line-height:1.5; dom-dir:ltr" ><c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font-weight:b old"> </c><c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font-weight:bold"></c><c props="font-size:8pt">C0, C1, C2, C3, C4, C5, C6 , C7 ___________________________ (</c><c props="lang:en-US; font-size:8pt; fo nt-family:Times New Roman; font-weight:bold; font-style:italic">prone: supine: seated: drop: instrument </c></p> <p style="Normal" xid="45" props="text-align:left; line-height:1.5; dom-dir:ltr" ><c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font-weight:b old"> </c><c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font-weight:bold"></c><c props="font-size:8pt">T1, T2, T3, T4, T5, T6, T7 , T8, T9, T10, T11, T12 _____________________ (</c><c props="lang:en-US; f ont-size:8pt; font-family:Times New Roman; font-weight:bold; font-style:italic"> prone: anterior: drop: instrument: </c></p> <p style="Normal" xid="46" props="text-align:left; line-height:1.5; dom-dir:ltr" ><c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font-weight:b old"> </c><c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font-weight:bold"></c><c props="font-size:8pt"> L1, L2, L3, L4, L5, Sac, LIlium, R-Ilium _______ (</c><c props="lang:en-US; font-size:8pt; font-family:T imes New Roman; font-weight:bold; font-style:italic">side posture: prone: drop : seated: instrument: distraction</c></p> <p style="Normal" xid="47" props="text-align:left; line-height:1.5; dom-dir:ltr" ><c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font-weight:b old; font-style:italic"> </c><c props="lang:en-US; font-size:8pt; font-fami ly:Times New Roman; font-weight:bold; font-style:italic"></c><c props="lang:en-U S; font-size:8pt; font-family:Times New Roman; font-weight:bold">L / R Shoulder , L / R Elbow, L / R Wrist, L / R Hip, L / R Knee, L / R Ankle, _ _________ (</c><c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font-weight:bold; font-style:italic">instr: manual: drop)</c></p> <p style="Normal" xid="48" props="text-align:left; line-height:1.0; dom-dir:ltr" ><c props="lang:en-US; font-weight:bold; font-family:Times New Roman; font-size: 8pt; font-style:italic">PLAN /PROTOCOL/ RECOMMENDATIONS</c><c props="lang:en-US; font-weight:bold; font-family:Times New Roman; font-size:8pt; font-style:italic "></c></p> <p level="1" listid="1000" parentid="0" style="Normal" xid="49" props="list-styl e:Numbered List; start-value:1; dom-dir:ltr; margin-left:0.2500in; text-indent:0.2500in; line-height:1.0; text-align:left; field-font:Times New Roman"><field t ype="list_label" xid="50" props="text-decoration:none; font-weight:bold; font-si ze:8pt"></field><c props="text-decoration:none; font-weight:bold; font-size:8pt" > </c><c props="text-decoration:none; font-weight:bold; font-size:8pt"></c ><c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font-weight:b old">Based upon presenting symptoms, objective findings and clinical assessment, treatment consisted of the following procedures:</c></p> <p style="Normal" xid="51" props="text-align:left; text-indent:0.2500in; line-he ight:1.5; dom-dir:ltr"><c props="lang:en-US; font-size:8pt; font-family:Times Ne

w Roman; font-weight:bold">___ </c><c props="lang:en-US; font-size:8pt; font-fam ily:Times New Roman; font-weight:bold"></c><c props="font-size:8pt">Chiropractic Manipulative Therapy ___CMT 1-2, ___ CMT 3-4, ___ Extremity ______________ ____________</c></p> <p style="Normal" xid="3" props="text-align:left; text-indent:0.2500in; line-hei ght:1.5; dom-dir:ltr"><c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font-weight:bold">Therapeutics Modalities: </c><c props="lang:en-US; f ont-size:8pt; font-family:Times New Roman; font-weight:bold"></c><c props="fontsize:8pt">Myofascial Release -- Mechanical Traction -- EMS/IF -- Hot/Cold Th erapy -- InfraRed</c></p> <p style="Normal" xid="52" props="text-align:left; line-height:1.5; dom-dir:ltr" ><c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font-weight:b old"> </c><c props="lang:en-US; font-size:8pt; font-family:Times New Roman ; font-weight:bold"></c><c props="font-size:8pt">Ultrasound(attended) Pulsed/Con .__________ Massage Therapy-15/30min._____ </c></p> <p style="Normal" xid="18" props="text-align:left; line-height:1.5; dom-dir:ltr" ><c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font-weight:b old"> </c><c props="lang:en-US; font-size:8pt; fon t-family:Times New Roman; font-weight:bold"></c><c props="font-size:8pt">Locatio n____________________________________Intensity_________Time___________</c></p> <p style="Normal" xid="53" props="text-align:left; line-height:1.5; dom-dir:ltr" ><c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font-weight:b old"> </c><c props="lang:en-US; font-size:8pt; font-family:Times New Roma n; font-weight:bold"></c><c props="font-family:Times New Roman; text-decoration: none; color:000000; font-size:8pt; text-position:normal; font-weight:bold; fontstyle:normal; lang:en-US">Kinetic / Therapeutic Activity__ Neuromuscular ReEd___ Attended Active Exercise______________________________</c></p> <p style="Normal" xid="5" props="font-family:Times New Roman; font-size:12pt; do m-dir:ltr; color:000000; text-decoration:none; text-align:left; line-height:1.5; text-position:normal; font-weight:normal; font-style:normal"><c props="font-fam ily:Times New Roman; text-decoration:none; color:000000; font-size:8pt; text-pos ition:normal; font-weight:bold; font-style:normal; lang:en-US"> </c><c props="font-family:Times New Roman; text-decoration:none; c olor:000000; font-size:8pt; text-position:normal; font-weight:bold; font-style:n ormal; lang:en-US"></c>Location_____________________________________Time: 15mi n. / 30min. Stretching / Strengthening / Conditioning</p> <p style="Normal" xid="17" props="font-family:Times New Roman; font-size:12pt; d om-dir:ltr; color:000000; text-decoration:none; text-align:left; line-height:1.5 ; text-position:normal; font-weight:normal; font-style:normal"><c props="font-fa mily:Times New Roman; text-decoration:none; color:000000; font-size:8pt; text-po sition:normal; font-weight:bold; font-style:normal; lang:en-US"> </c><c props="font-family:T imes New Roman; text-decoration:none; color:000000; font-size:8pt; text-position :normal; font-weight:bold; font-style:normal; lang:en-US"></c>Dr.'s Initials____ __________ Frequency of Treatments_____________</p> <p style="Normal" xid="54" props="text-align:left; text-indent:0.2500in; line-he ight:1.5; dom-dir:ltr"><c props="lang:en-US; font-size:8pt; font-family:Times Ne w Roman; font-weight:bold">___ Home Instruction: ___ Ice Therapy, ______ Tracti on _______, Strapping/Taping_______________________________</c><c props="lang :en-US; font-size:8pt; font-family:Times New Roman; font-weight:bold"></c></p> <p style="Normal" xid="55" props="text-align:left; text-indent:0.2500in; line-he ight:1.5; dom-dir:ltr"><c props="lang:en-US; font-size:8pt; font-family:Times Ne w Roman; font-weight:bold">___ Personal Stretch / Exercise Program: __ neck, __ back, __ UE, __ LE, __ whole body, ____________________________</c><c props="la ng:en-US; font-size:8pt; font-family:Times New Roman; font-weight:bold"></c></p> <p level="1" listid="1001" parentid="0" style="Normal" xid="56" props="list-styl e:Numbered List; start-value:2; dom-dir:ltr; margin-left:0.2500in; text-indent:0.2500in; line-height:1.5; text-align:left; field-font:Times New Roman"><field t ype="list_label" xid="57" props="text-decoration:none; font-weight:bold; font-si ze:8pt"></field><c props="text-decoration:none; font-weight:bold; font-size:8pt"

> </c><c props="text-decoration:none; font-weight:bold; font-size:8pt"></c ><c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font-weight:b old">The following recommendations are made for Clinical Management of this pati ent: MMI Dismissal (Failure to Follow Treatment Plan)</c></p> <p style="Normal" xid="58" props="text-align:left; text-indent:0.2500in; line-he ight:1.5; dom-dir:ltr"><c props="lang:en-US; font-size:8pt; font-family:Times Ne w Roman; font-weight:bold">___ </c><c props="lang:en-US; font-size:8pt; font-fam ily:Times New Roman; font-weight:bold"></c><c props="font-size:8pt">Continue Car e Plan, ____ Modify Care Plan, ___ Re-Examination, ___ Referral for Further Evaluation: _____________</c></p> <p style="Normal" xid="59" props="text-align:left; text-indent:0.2500in; line-he ight:1.5; dom-dir:ltr"><c props="lang:en-US; font-size:8pt; font-family:Times Ne w Roman; font-weight:bold">___ </c><c props="lang:en-US; font-size:8pt; font-fam ily:Times New Roman; font-weight:bold"></c><c props="font-size:8pt">Referral for diagnostic / imaging assessment to include: ______________</c></p> <p style="Normal" xid="60" props="text-align:left; line-height:1.5; dom-dir:ltr" ><c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font-weight:b old">COMMENTS:__________________________________________________________________ _____________________________________</c></p> <p style="Normal" xid="69" props="text-align:left; line-height:1.5; dom-dir:ltr" ><c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font-weight:b old">___________________________________________________________________________ ________________________________________</c></p> <p style="Normal" xid="71" props="text-align:left; line-height:1.5; dom-dir:ltr" ><c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font-weight:b old">___________________________________________________________________________ ________________________________________</c></p> <p style="Normal" xid="70" props="text-align:left; line-height:1.5; dom-dir:ltr" ><c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font-weight:b old">Goals______________________________________________________________________ ________________________________________</c></p> <p style="Normal" xid="72" props="text-align:left; line-height:1.5; dom-dir:ltr" ><c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font-weight:b old">___________________________________________________________________________ ________________________________________</c></p> <p style="Normal" xid="16" props="text-align:left; line-height:1.5; dom-dir:ltr" ><c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font-weight:b old"></c></p> <p style="Normal" xid="13" props="text-align:left; line-height:1.5; dom-dir:ltr" ><c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font-weight:b old">Doctor's Signature</c><c props="lang:en-US; font-size:8pt; font-family:Time s New Roman; font-weight:bold"></c><c props="font-size:8pt">____________________ ___________D.C. Patient's Signature______________________________ ______________</c></p> <p style="Normal" xid="7" props="text-align:left; line-height:1.5; dom-dir:ltr"> <c props="lang:en-US; font-size:8pt; font-family:Times New Roman; font-weight:bo ld"></c></p> <p xid="61"><c props="font-weight:bold; font-size:8pt"></c></p> <p xid="62"><c></c></p> </section> <section type="footer" id="9" xid="63"> <p style="Footer" xid="64" props="text-align:right; tabstops:3.0000in/C,6.0000in /C; line-height:1.0; dom-dir:ltr"><c props="lang:en-US; font-weight:bold; font-f amily:Times New Roman; font-size:8pt; font-style:italic"> </c><c props="lang:en-US; font-weight:bold; font-family:Times New Roman; fo nt-size:8pt; font-style:italic"></c> </p> <p style="Normal" xid="65" props="text-align:left; line-height:1.0; dom-dir:ltr" ></p>

</section> </abiword>