Re-Evaluation

Mr.

Mrs.

Ms.

Patient Name

Date

Subjectives

C/S

T/S

L/S

SIJ

Hip

Knee

Ankle

Shoulder

Elbow

Wrist

Foot

HA

Dizziness

Blurred Vision

Nausea/Vomiting

Tinnitus

PTA

Diff. Sleeping

Other

Objectives

N/A

Assessment

Imaging Reviews

Notes

Plan

Treatment Recommendations

Chiropractic

Acupuncture

---

Electric Stimulation

Infrared

Mechanical Traction

Myofascial relase

Neuromuscular Re-education

Therapeutic exercises

Ultrasound

Frequency

01234567 times per week, for 01234567891011 weeks

Re-eval in 01234567891011 weeks

Home Care

Core Program

Ice Pack/Hot Pack

Stretches

Ligament Stability Program

Specialist Referrals

Orthopedic consultation

Pain management consultation

Other

Imaging Referrals

N/A

Report

Re-evaluation summary for PATIENT on 8/21/2024

Patient presents today for a re-evaluation

Treatment/Rationale:

See diagnosis for assessment.

The patient's overall condition: remains status post injury.

The short-term goals are to decrease level of acute pain, decrease the inflammation, decrease the swelling, and improve the patient P.R.O.M..

The long-term goals are to decrease the likelihood of further joint damage, decrease the level of chronic pain, educate the patient in techniques to prevent further re-injury, improve overall function of the affected areas, and improve the joint mobilization of the affected areas.