Stephen Kaplan, L.Ac, (NJ: 25MZ00059400) (NY 875-1)

Stephen Kaplan, L.Ac, (NJ: 25MZ00059400) (NY 875-1)

SUBJECTIVE EXAMINATION

Initial Examination Re-Examination Discharge IME

START TIME: END TIME:

Today’s Date / /
Treatments To Date
Patient Name / Date of Accident: /
Age: Gender: M F Date of Birth: / Height: ' " Weight: lbs
Section 1 / Subjective History
History / Chief Complaint
Location / Quality / Level 0-10 / Time / Setting / Factors Worse / Factors Better
Sharp Dull
Numb Other
Radiculopathy: / 0 1 2 3
4 5 6
7 8 9 10 / Everyday
Every night
Constant
Off & On / Anywhere / Unknown / Unknown
Sharp Dull
Numb Other
Radiculopathy: / 0 1 2 3
4 5 6
7 8 9 10 / Everyday
Every night
Constant
Off & On / Anywhere / Unknown / Unknown
Sharp Dull
Numb Other
Radiculopathy: / 0 1 2 3
4 5 6
7 8 9 10 / Everyday
Every night
Constant
Off & On / Anywhere / Unknown / Unknown
Sharp Dull
Numb Other
Radiculopathy: / 0 1 2 3
4 5 6
7 8 9 10 / Everyday
Every night
Constant
Off & On / Anywhere / Unknown / Unknown
Sharp Dull
Numb Other
Radiculopathy: / 0 1 2 3
4 5 6
7 8 9 10 / Everyday
Every night
Constant
Off & On / Anywhere / Unknown / Unknown
Additional Symptoms / Dizziness:Yes No Same Better Worse Headache:Yes No Same Better Worse Bleeding: Yes No Same Better Worse Appetite:Good Bad Same Better Worse Digestion:Good Bad Same Better Worse Elimination:Good Bad Same Better Worse SleepQual:Good Bad Same Better Worse Temperature:Good Bad Same Better Worse
Cause / Auto Accident (see section 2) Sports Injury Home Injury Work Injury Disease Related
Other:
Section 2 / FOR AUTOMOBILE ACCIDENT PATIENTS ONLY:
Were You A / Driver Passenger ( Front Rear Left Middle Right) Seatbelt No Seatbelt
Pedestrian Bus Bicycle Other:
Your Vehicle Impacted on the / Front Passenger Side Driver Side Rear
Did You Lose Consciousness? / Yes No
Did You Go To A Hospital? / Yes No When? Name:
Section 3 / Other Physician, Specialists, Treatments Consulted
Have you consulted a physician regarding this? / Yes No
Physician’s Name: Specialty?
Diagnosis:
List Other Treatments Received?
When started / Medical Type:
Acupuncture Chiropractic Physical Therapy
Are Other Treatments Working? / Yes No Explain:
Section 4 / Past Medical History
Have you had any other: / Automobile Accident Injury Trauma Yes No
Explain:
Injuries:
Injuries resolved percentage:
Do you have any diseases or conditions? / Yes No
Please list:
Have you had any surgeries? / Yes No
Please list with dates:
Are you taking any medications? / Yes No
Please list:
Allergies: / Yes No
Please list:
Tests Performed? / Yes No
Please list:

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