New Patient Evaluation (Osteopathic/OMM)

Date of Service: [Date]

Patient Name: [Full name]

DOB: [MM/DD/YYYY]

MRN: [Medical record number]

Location/Site: [Clinic or facility]

Clinician: [Name, credentials]

Chief Complaint

[Primary symptom or problem, with optional patient quote and duration]

History of Present Illness

[Narrative description of current problem] (Characterize location, quality, severity on 0–10 scale, onset/duration, timing, aggravating/alleviating factors, associated symptoms, and functional impact including work limitations, ADLs, sleep, and activity tolerance. Include prior evaluation and treatments with responses—imaging, manual therapy, PT, medications—and note mechanism or inciting event if relevant. Integrate red flag screening within the narrative, documenting pertinent negatives for neurologic deficits, bowel/bladder changes, fever, unexplained weight loss, cancer history, fracture risk, and anticoagulation status. Incorporate osteopathic context when relevant such as posture/ergonomics, breathing mechanics, stress/sleep factors. Document patient goals and preferences regarding manual medicine when discussed.)

Review of Systems

(Focused ROS relevant to the complaint and OMT safety. Document pertinent positives and negatives clearly. Avoid blanket statements unless a comprehensive review was truly performed.)

• Neurologic: [Numbness, tingling, weakness, balance changes, headaches, dizziness—document positives and pertinent negatives]
• Constitutional: [Fever, chills, fatigue, weight changes] (Include only if relevant.)
• Other Systems: [Additional pertinent symptoms] (Include only systems reviewed.)

Past History

Past Medical History: [Relevant conditions]

Past Surgical History: [Surgeries and dates] (Note any prior spine surgery or instrumentation.)

Medications: [Current medications and doses] (State reconciliation status.)

Allergies: [Allergen and reaction type]

Family History: [Relevant items only]

Social History: [Occupation/ergonomics, activity level, tobacco/alcohol use, relevant psychosocial factors]

Pregnancy Status: [Status] (Include only when relevant.)

Records Reviewed: [External records, source, date, and key findings] (Include only if records were reviewed.)

Vital Signs

[BP] | [HR] | [RR] | [Temp] | [SpO2] | [Height] | [Weight] | [BMI]

Physical Examination

(Include elements actually performed. For customary elements not performed, state deferred/declined/contraindicated with rationale.)

• General: [Appearance, distress level]
• Neurologic: [Strength, reflexes, sensation, coordination, gait/balance] (Include only components examined.)
• Provocative Tests: [Straight leg raise, Spurling, other tests with laterality and results] (Include only if performed.)
• Musculoskeletal: [Inspection/posture, ROM with quantification, tenderness, joint-specific findings, special tests] (Specify side/level as applicable.)
• Other Systems: [Cardiovascular, respiratory, abdominal, skin, or other exam findings] (Include only when clinically indicated.)

Osteopathic Structural Exam

(Document regions actually assessed. For each region with somatic dysfunction, include TART elements and segmental diagnoses. For regions assessed without dysfunction, state "No somatic dysfunction identified." Omit regions not examined.)

• Head: [TART findings with segmental diagnoses / No somatic dysfunction identified]
• Cervical: [TART findings with segmental diagnoses / No somatic dysfunction identified]
• Thoracic: [TART findings with segmental diagnoses / No somatic dysfunction identified]
• Lumbar: [TART findings with segmental diagnoses / No somatic dysfunction identified]
• Sacrum: [TART findings with segmental diagnoses / No somatic dysfunction identified]
• Pelvis: [TART findings with segmental diagnoses / No somatic dysfunction identified]
• Ribs: [TART findings with segmental diagnoses / No somatic dysfunction identified]
• Upper Extremity: [TART findings with segmental diagnoses / No somatic dysfunction identified]
• Lower Extremity: [TART findings with segmental diagnoses / No somatic dysfunction identified]
• Abdomen/Viscera: [TART findings with segmental diagnoses / No somatic dysfunction identified]
• Postural/Gait/Respiratory Mechanics: [Pertinent findings] (Include only if assessed.)

Assessment

(Problem-oriented list by clinical priority.)

Medical Diagnoses

• [Primary diagnosis with brief clinical reasoning]
• [Additional diagnoses] (Include only if relevant.)
• [Differential diagnoses] (Include only if etiology unclear or concerning features present.)

Somatic Dysfunction

• [Region]: [Somatic dysfunction diagnosis aligned with OSE findings]
• [Additional regions as applicable]

OMT Appropriateness

[OMT indicated and performed today / OMT indicated but deferred / OMT not indicated]—[rationale, including any contraindications or precautions influencing technique selection]

Plan

(Problem-oriented with subheadings mirroring Assessment. Include only items discussed and decided today.)

[Problem 1]

• Diagnostics: [Tests ordered with rationale]
• Medications: [Name, dose, route, frequency, duration; safety counseling]
• Non-Pharmacologic: [PT referral, home exercises, ergonomic modifications, activity guidance]
• Education: [Key points discussed and patient preferences]
• Follow-Up: [Timeframe and return precautions]

Somatic Dysfunction

• OMT: [OMT performed today (see OMT Procedure Note) / OMT deferred—reason / OMT not indicated—rationale]
• Adjunctive Measures: [Self-care, stretches, breathing exercises, posture/ergonomics, heat/ice, activity guidance]

OMT Procedure Note

(Include only if OMT was performed; omit entire section otherwise. Regions treated must align with somatic dysfunction diagnoses in Assessment.)

Indication: [Link to diagnosed somatic dysfunction and symptom/functional impact]

Consent: [Risks, benefits, and alternatives discussed; patient consented / patient declined—document discussion]

Regions Treated: [List each body region]

Techniques: [Techniques applied—e.g., soft tissue, myofascial release, muscle energy, counterstrain, HVLA, BLT, cranial]

Response: [Immediate post-treatment changes in pain level, ROM, or palpatory findings]

Tolerance: [Tolerated well without adverse events / Description of complications and actions taken]

Post-Treatment Instructions: [Hydration, expected soreness, activity guidance, warning signs prompting return]

Follow-up: [Interval and goals for next OMT session] (Include only if follow-up OMT planned.)