Chiropractic Initial Evaluation Note (New Patient)

Date of Service: [Date] [Start time – End time] | Location: [Clinic location] | Visit Type: [in-person / telehealth]

Patient: [Full name] | DOB: [DOB] | MRN: [MRN]

Rendering Provider: [Name, credentials] | Signature Status: [Unsigned / Signed]

Other Participants: [Scribe (note if AI-assisted) / Interpreter (language) / Chaperone] (Include only when applicable; omit line entirely if none.)

Administrative Context

(Include only when relevant.)

[Referral source and reason]
Case Type: [Workers' Compensation / Motor Vehicle Accident / Personal Injury] | Date of Injury: [Date] | Claim Number: [Number or "pending"] | Adjuster: [Name and contact]
[Consent to treat status] | [Consent for spinal manipulation per practice policy]

Chief Complaint

[Primary complaint in patient's own words, body region, laterality, duration] (One to two lines. Include secondary complaints only if addressed at this visit.)

History of Present Illness

[Narrative opening with chief complaint and onset context, progressing chronologically from onset to current status]

[Symptom details: location, radiation pattern, quality, severity 0–10, frequency, duration, variability] | [Aggravating factors] | [Relieving factors]

[Mechanism of injury with date and forces involved] (Include only if traumatic.) | [Functional impact on ADLs, work, sleep, recreation]

[Prior evaluations: imaging, ED/urgent care, specialty visits with results] | [Prior treatments and response: chiropractic, PT, medications, injections, self-care] | [Patient goals for treatment]

[High-safety items pertinent to the complaint] (Explicitly document presence or absence for red-flag symptoms relevant to the involved region, e.g., bowel/bladder changes for lumbar complaints.)

Red Flags / Safety Screening

(Include for all spine-related complaints or when spinal manipulation is planned. Document specific pertinent positives and negatives. May abbreviate or omit if complaint is clearly peripheral with no spinal intervention planned.)

• Constitutional: [Fever / chills / unexplained weight loss / night sweats – present or absent]
• Infection Risk: [Recent infection / immunosuppression / IV drug use / diabetes / indwelling hardware]
• Fracture Risk: [Significant trauma / osteoporosis / prolonged steroid use / cancer history]
• Neurologic Compromise: [Progressive weakness / numbness pattern / saddle anesthesia / bowel or bladder dysfunction / gait disturbance]
• Non-spinal Sources: [Visceral or vascular symptoms relevant to pain location]
• Cervical Manipulation Considerations: [Findings influencing technique selection or prompting referral] (Include only for cervical complaints.)

Past History

• PMH: [Major conditions impacting MSK/neuro risk or treatment tolerance]
• Surgical: [Spine/orthopedic surgeries or other relevant procedures]
• Prior Injuries: [Spine or extremity trauma; prior similar episodes]
• Medications: [Current medications including OTC; note anticoagulants and bone-affecting agents]
• Allergies: [Drug / latex / environmental with reaction type]
• Social: [Occupation and physical demands] | [Activity level] | [Tobacco/alcohol use] | [Psychosocial factors relevant to recovery]

Review of Systems

(Focused ROS aligned with chief complaint and safety screening. Document specific positives and negatives.)

• Musculoskeletal: [Pertinent findings relevant to involved regions]
• Neurologic: [Weakness / numbness / paresthesia / coordination or balance issues]
• Constitutional: [Fever / weight change / fatigue]
• Other Systems: [Additional systems as clinically indicated] (Include only if relevant.)

Baseline Outcome Measures

• Pain: [Region] [Severity 0–10 at rest / with activity] [Quality/temporal pattern]
• Patient-Reported Outcome Measure: [Instrument name] [Score] [Date] (Omit if not collected.)
• Functional Tolerance: [Sitting duration] | [Standing duration] | [Walking tolerance] | [Lifting tolerance] | [Sleep quality] | [Work status/restrictions]

Physical Examination

(Document pertinent positives and relevant negatives. Use laterality and objective measures where possible.)

• Observation: [Posture / deformity / guarding / swelling / skin changes / gait quality / antalgic patterns / functional movements]
• Palpation: [Tenderness location and severity] | [Tissue tone/texture changes] | [Trigger points]
• Range of Motion: [Region(s)] [Directions tested with degrees] [Pain provocation] [Asymmetry]
• Orthopedic/Provocative Tests: [Test name – side – result (positive/negative)] (Clarify what constitutes positive when ambiguous.)
• Neurologic Exam: [Sensation by dermatome] | [Motor strength by myotome with grades] | [Reflexes] | [Upper motor neuron signs] (Include when spine complaint, radicular symptoms, or red flags are present.)
• Imaging/Records Reviewed: [Type, date, key impressions] (Include only if reviewed at this visit.)

Segmental/Spinal Findings

(Required when spinal manipulation is planned. Document individualized, level-specific findings; avoid generic statements.)

Subluxation Evidence Basis: [Imaging with date / PART examination findings]

• Region: [Cervical / Thoracic / Lumbar / Sacral / Pelvic] | Level: [Specific level(s)]
  P (Pain/Tenderness): [Location and severity]
  A (Asymmetry/Misalignment): [Palpatory or postural findings]
  R (Range of Motion Abnormality): [Restriction by direction; end-feel; pain with motion]
  T (Tissue/Tone Changes): [Paraspinal tone/texture/edema/trigger points]
  Technique Considerations: [Planned technique(s) or modifications based on findings]
• (Repeat for each clinically relevant level/region.)

Assessment

• Working Diagnoses: [Diagnosis with region/laterality/acuity]; [Additional diagnoses] (List in priority order. Ensure correlation with documented subluxation levels when manipulation is planned.)
• Differential Diagnosis: [Differentials to rule in/out] (Include when diagnosis uncertain or red flags present.)
• Medical Necessity Rationale: [Link findings and functional deficits to proposed interventions] | [Appropriateness of chiropractic care vs. need for referral/imaging] | [Spinal manipulation: appropriate / contraindicated / requires modification]
• Prognosis: [Expected course] | [Factors affecting recovery]

Plan of Care

• Treatment Discussion: [Options discussed including no treatment] | [Benefits and material risks of spinal manipulation] | [Patient preference and agreement]
• Informed Consent: [Consent obtained for spinal manipulation; risks explained; questions answered] (Reference signed form if stored separately.)
• Treatment Plan: [Frequency] | [Duration of initial trial] | [Re-evaluation date] | [Regions/levels to be treated] | [Adjunct therapies] | [Home exercise program]
• Goals:
  • Short-term (2–4 weeks): [Pain reduction target: baseline → target] | [Functional tolerance improvements: baseline → target]
  • Long-term (4–8 weeks): [Functional restoration goals] | [Disability score target] | [Return to work/activities]
  • Reassessment: [Measures to be reassessed and timing]
• Activity Modifications: [Work restrictions] | [Activity limitations with duration]
• Referrals: [PCP / specialist / imaging with rationale] | Return Precautions: [Symptoms warranting urgent evaluation]

Treatment Rendered Today

(Include when treatment performed. If none, document "No treatment rendered today" with reason.)

• Spinal Manipulation/Mobilization: [Region(s)/level(s)] | [Technique(s)] | [Patient positioning]
• Adjunct Procedures: [Soft tissue therapy] | [Therapeutic exercise with dosage] | [Modalities with parameters] | [Taping/bracing]
• Patient Tolerance/Response: [Tolerance] | [Immediate symptom change] | [Adverse events or "none"]
• Patient Instructions: [Home exercises] | [Ice/heat guidance] | [Activity recommendations]

Authentication

Provider Signature: [Name, credentials] | [Date/time] (If scribed, rendering provider attests this note accurately reflects the encounter. Amendments must be entered as addenda with date/time and author; original content remains intact.)