Auto Narrative Report

Additional improvements needed
Initial examination and final examination with comparisons discribe meaning of Trigger points
Addition of malingerers tests and indicate the value of similar tests which give the same result. It removes subjectivity of the ortho tests and makes them more objective.

Add in perpetuating factors, ie overweight poor muscle tone,
stability factors
adaptative changes

Enter Date of Report:
Send this report to....




Regarding:
Mr. Ms. Miss Mrs.
Enter Patient First Name: Last name:
Enter Date of Accident:
Jump to Follow Up Exam

Page Index

Initial Exam date..


Long or Short Version of Initial exam report

Check here if you want the long version
Indicate the patient's position in the vehicle:

Head Rotation and angle of Impact

Did your vehicle strike another vehicle yes no

Was your vehicle struck by another vehicle? yes no

First Collision Second Collision
Was there a lateral component to the accident ie. Was either collision from the side. yes no

Were you wearing a seat belt? yes no

Did you brace for impact?

Which way were you facing at impact... facing straight ahead. left right

Check off the item and complete the sentence with the body part...
the patient struck the steering wheel...
steering wheel
windshield
left side door
right side door
left side window
right side window
roof
dashboard
other.. enter a complete sentence.

Did the seat back bend / break? yes no

Immediately following the accident patient felt...

he she also stated that he felt ....other...

I added frontal headache below but didn't work the script yet...

The car had no air bag...

the seat back broke...

visible seat belt sign...

The air bag deployed???

Emergency personal used "jaws of Life"...

Hospital Section:

Check here if The Patient went to a hospital.

  • the full name must be entered ie. [foo Medical Center], or [foo bar Hospital].
  • Was the patient admitted to the hospital? YESNO
    if yes how long? ie.. three days.
  • went to hosp when? at time of accident the next day two days later three days later about a week later
  • Transported by:

    • police carprivate transportationambulance

hold down the control key to make multiple selections

Select hospital treatment...

Other hospital treatment:

Additional history comments


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inside brackets this will skip a line.

If you don't want to skip a line... finish your sentence with
The use of any HTML formatting is permitted.

Page Index

Chief Complaints
neck pain
select the areas of radiation, if any... hold down the control key to make multiple selections
headache
Frontal Headache
upper back pain

Complaints .. Symptoms cont...

  Negative

Findings

Positive Findings
Left Right Bilateral
Temporal Headache neg Left Right Bilateral
Occipital Headache neg Left Right Bilateral
Migraine Headache neg Positive
Dizziness neg Positive
Ringing in Ears Negative Left Right Bilateral
Blurry Vision Negative Left Right Bilateral
Wrist Pain neg Left Right Bilateral
Jaw Pain neg Left Right Bilateral
Complete this sentence, or just leave none

In addition to the afore mentioned symptoms
the patient also complained of...

hold down the control key to make multiple selections
Complete this sentence, or just leave none

In addition to the afore mentioned symptoms
the patient also complained of numbness in the...

hold down the control key to make multiple selections
Low Back Pain
select the areas of radiation, if any... hold down the control key to make multiple selections
Hip Pain Negative Left Right Bilateral
Knee Pain Negative Left Right Bilateral
Foot Pain neg Left Right Bilateral

Additional symptoms

Remember... to start a new paragraph you must put a P inside brackets like this
If you want to just start a new line without skipping a line you must put a br inside of brackets like this use of any HTML formatting is permitted.

Page Index

Orthopedic Examination

You may complete the sentence by typing in the radiation text box...
ie. The Cervical Compression Test was positive on the left... you may want to enter in the radiation box... with pain produced into the left shoulder and radiating down to the elbow.
The output in the narrative will read
The Cervical Compression Test was positive on the left with pain produced into the left shoulder and radiating down to the elbow.

Neck and Upper Back

  Negative

Findings

Positive Findings
Left Right Bilateral Radiation
Max Foraminal Compression neg Left Right Bilateral
Jackson Cervical Compression neg Left Right Bilateral
Cervical Distraction neg Left Right Bilateral
Shoulder Depression neg Left Right Bilateral
George's Test neg Left Right Bilateral
Allen's Test neg Left Ulnar occlusion Left Radial occlusion Right Ulnar occlusion Right Radial occlusion
Adson's Test neg Left Right Bilateral
Wright's Test neg Left Right Bilateral
Soto Hall neg Positive

Low Back and Sacro Iliac Exam

  Negative

Findings

Positive Findings  
Left Right Bilateral Radiation
Bechterew Sitting Test neg Left Right Bilateral
Minor's Sign neg Positive
Kemp's Test neg Left Right Bilateral
Braggard Test neg Left Right Bilateral
Laseque Test neg Left Right Bilateral
Fabre Patrick Test neg Left Right Bilateral
Hibb's Test neg Left Right Bilateral
Nachlas' Test neg Left Right Bilateral
Ely's Test neg Left Right Bilateral
Yeoman's Test neg Left Right Bilateral
Heel Walk Test neg Left Right Bilateral
Toe Walk Test neg Left Right Bilateral

Additional Ortho


Page Index

(Cerebellar Function Tests)
TestNormalAbnormal
Rhomberg Testnot tested normal abnormal
Heel-Toe Walknot tested normal abnormal
Rapid Handnot tested normal abnormal
Finger to Nosenot tested normal abnormal
Finger to Fingernot tested normal abnormal
Check Reflexnot tested normal abnormal

Vibratory Sense

Complete this sentence only if you want it printed!
A loss of vibratory sense was noted ...

Page Index

Trigger PointsMuscle Spasm

Additional Trigger Points

Additional Muscle Spasms

Page Index

Motion Palpation

Aberrant motion and a loss of function on an intersegmental level was noted in the

Additional Motion Palpation comments

Page Index

Neurological Evaluation

The cervical dermatomes checked were within normal limits.
No abnormalities were noted in the L1 through the S1 dermatomes.

Dermatome Sensitivity Testing
LEFT Dermatome RIGHT
Check to Omit C3
      from report
Check to Omit C4
      from report
Check to Omit C5
      from report
Check to Omit C6
      from report
Check to Omit C7
      from report
Check to Omit C8
      from report
Check to Omit T1
      from report

Lumbar Dermatome Sensitivity Testing
LEFT Dermatome RIGHT
Check to Omit L1
      from report
Check to Omit L2
      from report
Check to Omit L3
      from report
Check to Omit L4
      from report
Check to Omit L5
      from report
Check to Omit S1
      from report

Deep Tendon Reflexes

Deep Tendon Reflexes

Jaw 0 absent
+1 hypo
+2.. normal
+3 hyper
+4 hyper w/ clonus
+5 continued clonus
Left Extremity Right Extremity
Pectoral 0 absent
+1 hypo
+2.. normal
+3 hyper
+4 hyper w/ clonus
+5 continued clonus
 0 absent
+1 hypo
+2.. normal
+3 hyper
+4 hyper w/ clonus
+5 continued clonus
Biceps 0 absent
+1 hypo
+2.. normal
+3 hyper
+4 hyper w/ clonus
+5 continued clonus
 0 absent
+1 hypo
+2.. normal
+3 hyper
+4 hyper w/ clonus
+5 continued clonus
Triceps 0 absent
+1 hypo
+2.. normal
+3 hyper
+4 hyper w/ clonus
+5 continued clonus
 0 absent
+1 hypo
+2.. normal
+3 hyper
+4 hyper w/ clonus
+5 continued clonus
Left Extremity Right Extremity
Brachioradialis 0 absent
+1 hypo
+2.. normal
+3 hyper
+4 hyper w/ clonus
+5 continued clonus
 0 absent
+1 hypo
+2.. normal
+3 hyper
+4 hyper w/ clonus
+5 continued clonus
Patella 0 absent
+1 hypo
+2.. normal
+3 hyper
+4 hyper w/ clonus
+5 continued clonus
 0 absent
+1 hypo
+2.. normal
+3 hyper
+4 hyper w/ clonus
+5 continued clonus
Left Extremity Right Extremity
Medial Hamstring 0 absent
+1 hypo
+2.. normal
+3 hyper
+4 hyper w/ clonus
+5 continued clonus
 0 absent
+1 hypo
+2.. normal
+3 hyper
+4 hyper w/ clonus
+5 continued clonus
Achilles 0 absent
+1 hypo
+2.. normal
+3 hyper
+4 hyper w/ clonus
+5 continued clonus
 0 absent
+1 hypo
+2.. normal
+3 hyper
+4 hyper w/ clonus
+5 continued clonus
Page Index

Manual muscle testing Weaknesses noted
right dominant left dominant
Left Upper Extremity Right Upper Extremity
Left Lower Weakness Right Lower Weakness

Additional Manual Muscle tests

Attaching a more complete muscle testing report

Additional Neuro

Skip Follow Up Examination


Followup Exam date..


Long or Short Version of follow up exam report

Check here if you want the long version

Followup Chief Complaints
neck pain
select the areas of radiation, if any... hold down the control key to make multiple selections
headache
Frontal Headache
upper back pain

Followup Complaints .. Symptoms cont...

  Negative

Findings

Positive Findings
Left Right Bilateral
Temporal Headache neg Left Right Bilateral
Occipital Headache neg Left Right Bilateral
Migraine Headache neg Positive
Dizziness neg Positive
Ringing in Ears Negative Left Right Bilateral
Blurry Vision Negative Left Right Bilateral
Wrist Pain neg Left Right Bilateral
Jaw Pain neg Left Right Bilateral
Complete this sentence, or just leave none

In addition to the afore mentioned symptoms
the patient also complained of...

hold down the control key to make multiple selections
Low Back Pain
select the areas of radiation, if any... hold down the control key to make multiple selections
Hip Pain Negative Left Right Bilateral
Knee Pain Negative Left Right Bilateral
Foot Pain neg Left Right Bilateral
Complete this sentence, or just leave none

In addition to the afore mentioned symptoms
the patient also complained of numbness in the...

hold down the control key to make multiple selections

Followup Additional symptoms

Remember... to start a new paragraph you must put a P inside brackets like this
If you want to just start a new line without skipping a line you must put a br inside of brackets like this use of any HTML formatting is permitted.

Page Index

Followup Orthopedic Examination

You may complete the sentence by typing in the radiation text box...
ie. The Cervical Compression Test was positive on the left... you may want to enter in the radiation box... with pain produced into the left shoulder and radiating down to the elbow.
The output in the narrative will read
The Cervical Compression Test was positive on the left with pain produced into the left shoulder and radiating down to the elbow.

Neck and Upper Back

  Negative

Findings

Positive Findings
Left Right Bilateral Radiation
Max Foraminal Compression neg Left Right Bilateral
Jackson Cervical Compression neg Left Right Bilateral
Cervical Distraction neg Left Right Bilateral
Shoulder Depression neg Left Right Bilateral
George's Test neg Left Right Bilateral
Allen's Test neg Left Ulnar occlusion Left Radial occlusion Right Ulnar occlusion Right Radial occlusion
Adson's Test neg Left Right Bilateral
Wright's Test neg Left Right Bilateral
Soto Hall neg Positive

Followup Low Back and Sacro Iliac Exam

  Negative

Findings

Positive Findings  
Left Right Bilateral Radiation
Bechterew Sitting Test neg Left Right Bilateral
Minor's Sign neg Positive
Kemp's Test neg Left Right Bilateral
Braggard Test neg Left Right Bilateral
Laseque Test neg Left Right Bilateral
Fabre Patrick Test neg Left Right Bilateral
Hibb's Test neg Left Right Bilateral
Nachlas' Test neg Left Right Bilateral
Ely's Test neg Left Right Bilateral
Yeoman's Test neg Left Right Bilateral
Heel Walk Test neg Left Right Bilateral
Toe Walk Test neg Left Right Bilateral

Followup Additional Ortho


Page Index

(Cerebellar Function Tests)
TestNormalAbnormal
Rhomberg Testnot tested normal abnormal
Heel-Toe Walknot tested normal abnormal
Rapid Handnot tested normal abnormal
Finger to Nosenot tested normal abnormal
Finger to Fingernot tested normal abnormal
Check Reflexnot tested normal abnormal

Page Index

Follow up Trigger PointsFollow up Muscle Spasm

Follow up Additional Trigger Points

Page Index

Follow up Additional Muscle Spasms

Page Index

Followup Motion Palpation

Aberrant motion and a loss of function on an intersegmental level was noted in the

Additional Motion Palpation comments

Page Index

Followup Neurological Evaluation

The cervical dermatomes checked were within normal limits.
No abnormalities were noted in the L1 through the S1 dermatomes.

Followup Dermatome Sensitivity Testing
LEFT Dermatome RIGHT
Check to Omit C3
      from report
Check to Omit C4
      from report
Check to Omit C5
      from report
Check to Omit C6
      from report
Check to Omit C7
      from report
Check to Omit C8
      from report
Check to Omit T1
      from report

Lumbar Dermatome Sensitivity Testing
LEFT Dermatome RIGHT
Check to Omit L1
      from report
Check to Omit L2
      from report
Check to Omit L3
      from report
Check to Omit L4
      from report
Check to Omit L5
      from report
Check to Omit S1
      from report

Vibratory Sense

Complete this sentence only if you want it printed!
A loss of vibratory sense was noted ...

Followup Deep Tendon Reflexes

Deep Tendon Reflexes

Jaw 0 absent
+1 hypo
+2.. normal
+3 hyper
+4 hyper w/ clonus
+5 continued clonus
Left Extremity Right Extremity
Pectoral 0 absent
+1 hypo
+2.. normal
+3 hyper
+4 hyper w/ clonus
+5 continued clonus
 0 absent
+1 hypo
+2.. normal
+3 hyper
+4 hyper w/ clonus
+5 continued clonus
Biceps 0 absent
+1 hypo
+2.. normal
+3 hyper
+4 hyper w/ clonus
+5 continued clonus
 0 absent
+1 hypo
+2.. normal
+3 hyper
+4 hyper w/ clonus
+5 continued clonus
Triceps 0 absent
+1 hypo
+2.. normal
+3 hyper
+4 hyper w/ clonus
+5 continued clonus
 0 absent
+1 hypo
+2.. normal
+3 hyper
+4 hyper w/ clonus
+5 continued clonus
Left Extremity Right Extremity
Brachioradialis 0 absent
+1 hypo
+2.. normal
+3 hyper
+4 hyper w/ clonus
+5 continued clonus
 0 absent
+1 hypo
+2.. normal
+3 hyper
+4 hyper w/ clonus
+5 continued clonus
Patella 0 absent
+1 hypo
+2.. normal
+3 hyper
+4 hyper w/ clonus
+5 continued clonus
 0 absent
+1 hypo
+2.. normal
+3 hyper
+4 hyper w/ clonus
+5 continued clonus
Left Extremity Right Extremity
Medial Hamstring 0 absent
+1 hypo
+2.. normal
+3 hyper
+4 hyper w/ clonus
+5 continued clonus
 0 absent
+1 hypo
+2.. normal
+3 hyper
+4 hyper w/ clonus
+5 continued clonus
Achilles 0 absent
+1 hypo
+2.. normal
+3 hyper
+4 hyper w/ clonus
+5 continued clonus
 0 absent
+1 hypo
+2.. normal
+3 hyper
+4 hyper w/ clonus
+5 continued clonus
Page Index

Followup Manual muscle testing Weaknesses noted
right dominant left dominant
Left Upper Extremity Right Upper Extremity
Left Lower Weakness Right Lower Weakness

Followup Additional Manual Muscle tests

Attaching a more complete muscle testing report

Followup Additional Neuro

Page Index

Xray Section

Date of Xrays
Which spinal regions were xrayed?
X-ray findings reveal the presence of a sprain/strain soft tissue injury.
There are no apparent fractures, osseous pathology, or congenital bony abnormalities noted.
Cervical Osteophyte formations with loss of disc height at...

George s line

A break in georges line at...
loss of cervical lordosis
Kyphotic cervical spine
Lumbar Osteophyte formations with loss of disc height at...
There was a loss of lumbar rotation on AP Lat flexion studies
X-ray findings reveal the presence of a sprain/strain soft tissue injury.
There are no apparent fractures or osseous pathology noted.
There are no apparent congenital bony abnormalities noted.
Facet Tropism is noted.

Additional Xray


Page Index

Diagnosis

Diagnosis spine

Extremity sprain/strain

Fracture

Contusion... head

Muscoloskeletal System/Spine GROUP

Thoracic Spine GROUP

Lumbar/Lumbosacral GROUP

Sacroiliac/Coccyx GROUP

Pelvis and Hip GROUP

Additional Diagnosis

You may want to start a new heading within heading tags like...

Page Index

Additional Studies Completed with report attached:

Xray report
Range of Motion
MRI Report
Muscle Strength Study
Nerve Conduction Velocity
Electromyelograph
Dermatomal Somatosensory Evoked Potential
Electroencephalograph
Neck Pain Disability Index Questionnaire
The Revised Oswestry Disability Index for Low Back Pain/Dysfunction

Additional Reports attached

remember to use a or a at the end of each sentence.

Significant findings

MRI...
NCV...
DSEP..
EMG...

Negative NCS Findings with a positive disc

Page Index

Treatment Plan

MRI Recommendation/Request

Nerve Conduction Study Request

Patient to be referred for 2nd opinion?
2nd opinion is attached

Treatment Frequency
Chiropractic Manipulative Therapy...
Motorized intersegmental traction...
Massage Therapy...
Therapeutic exercises...
Cyrotherapy...
Hot Packs...
Ultrasound...

Additional Treatment

Page Index

Additional Discussion

You may want to start a new heading within heading tags like...

Page Index

Prognosis:

guarded... no permanency mentioned
poor... permanency mentioned
alternate poor..2... permanency mentioned
alternate poor..3... permanency mentioned

Create your own Prognosis. Enter the selections from your prognosis sheet, with each number separated by a comma ","

Prognosis:

Initial Exam Index Follow Up Exam Index
Initial Exam and History Jump to Follow Up Exam
Chief Complaints FU Chief Complaints
Orthopedic Exam FU Orthopedic Exam
Cerebellar Exam FU Cerebellar Exam
Trigger Points.. M Spasm FU Trigger Pts.. M Spasm
Motion Palpation FU Motion Palpation
Neuro..Derms.. Vib.. DTR's FU Neuro..Derms.. Vib.. DTR's
Muscle weakness.. add neuro FU Muscle weakness.. add neuro
X-Ray Section Diagnosis Section
Attached Studies... Reports Treatment Plan
Discussion Section Prognosis Section