OFFICE NAME Chiropractor:

Chiropractic Assessment

Persons Name: Date:

Chief Complaint: / Onset: Acute / Chronic / Insidious / Recurrent
Prior Occurrence: / Radiations:
Symptom:
Location:
Duration:
Character: / Aggravating:
Relieving:
Other Complaints and Conditions: / Health History (Trauma, Hospitalizations, Medications, Etc.)

Kinesiopathology

C 0 2 4 6 T 1 3 5 7 9 11 L 1 3 5 S R

1 3 5 7 2 4 6 8 10 12 2 4 L

Myopathology

Motor Testing:

5/5 B/L C5-T1 Other

5/5 B/L L4-S1 Other

Neuropathophysiology

Deep Tendon Reflexes:

2+ B/L C5-7 Other

2+ B/L L4, S1 Other

Sensory:

Light Touch: Arm & Leg Derm. U/R Other

Pin Wheel: Arm & Leg Derm. U/R Other

Plantar Response: N Down-going B/L

Babinski: R L

© Chiropractic Excellence Examination 2–1

OFFICE NAME Chiropractor:

Cervical

Kemp’s N B/L + R + L

Compression N B/L + R + L

Doorbell N B/L + R + L

Traction No Change Relieving

Soto Hall Normal Positive

Valsalva Normal Positive


Thoracic

Adson’s N B/L + R + L

Military N B/L + R + L

Abduction N B/L + R + L

T1 Stretch N B/L + R + L

T2 Stretch N B/L + R + L

© Chiropractic Excellence Examination 2–1

OFFICE NAME Chiropractor:

© Chiropractic Excellence Examination 2–1

OFFICE NAME Chiropractor:

Range of Motion:

Cervical

Lumbar

Kemp’s N B/L + R + L

Heel/Toe (L4/S1) N B/L + R + L

Thomas N B/L + R + L

Aber Patrick N B/L + R + L

Gaenslan’s N B/L + R + L

Lumbar

SLR N B/L + R + L

Braggard’s N B/L + R + L

Ely’s N B/L + R + L

Hibb’s N B/L + R + L

Yeoman’s N B/L + R + L

© Chiropractic Excellence Examination 2–1

OFFICE NAME Chiropractor:

© Chiropractic Excellence Examination 2–1

OFFICE NAME Chiropractor:

Diagnosis

Vertebral Subluxation Complex (VSC) / Posterior Joint Syndrome: C/S T/S L/S F/S

Acute Sub-acute Chronic Other:______

Recommendations

© Chiropractic Excellence Examination 2–1

OFFICE NAME Chiropractor:

Correction of Vertebral Subluxation Complex (VSC) Refer:

© Chiropractic Excellence Examination 2–1