PATIENT INFORMATION

Name ________________________________________ Today’s Date _____________________

Date of Birth ______________ Height __________ Weight __________ Dominant Hand? R L

Address ________________________________ City ________________________ Zip ______

Phone (cell) _____________________________ Phone (other) ___________________________

email _________________________________________________ DL# ___________________

Health Insurance Company _________________________ Policy# _________________________

Address ________________________________________ City ________________ Zip ________

Adjuster ________________________________________ Phone _________________________

Car Insurance Company ___________________________________________________________

Address ________________________________________ City ________________ Zip ________

Adjuster ________________________________________ Phone _________________________

Agent __________________________________________ Phone _________________________

Policy # _________________________________ Claim # _______________________________

What Medical Payments Coverage? ___________ What Uninsured Motorist Coverage? ________

What Law Firm Represents You? ____________________________________________________

Address ________________________________________ City ________________ Zip _______

Your Lawyer’s Name? _____________________________ Phone _________________________

Patient #For office use only

For office use only

Name of Insured on your Car Policy _________________________

Date of Loss/Accident? ______________ Date you first saw Doctor after accident __________

Cost of all medical treatment since the accident? $ ______________________________________

How much income have you lost since the accident $ ____________________________________

What is the property damage (repair amount) of your car? $ _______________________________

any

Name of your Personal M.D. ___________________________ Phone ______________________

Address ______________________________________City __________________ Zip ________

Write any Ambulance, Hospital, M.D., Chiropractor, Dentist, Acupuncturist, PT, etc., since accident

Name Type Phone# Amount of Bill Records Rec’d

_____________________________ ___ ______________ ____________ ____________

_____________________________ ___ ______________ ____________ ____________

_____________________________ ___ ______________ ____________ ____________

_____________________________ ___ ______________ ____________ ____________

HBTInstutute.comC

Please use other side of page to write additional doctors & hospitals

SleepinessNausea/vomitingDifficulty ConcentratingDay Dreaming/Staring Mindless StaringMood SwingsAgitationSadness or tearfulBlurry VisionDouble VisionDisorientedConfusedDifficulty SpeakingFeelings of Isolation from OthersAttention ProblemsAppetite ChangePupils Different SizesRoom Spins/ Woozy FeelingBalance ProblemsDifficulty WalkingDifficulty Focusing/Easily DistractedVery TiredDozing During The DayPersonality ChangeCan’t Remember NumbersReading ProblemsWriting ProblemsDifficulty with Adding/SubtractingPoor AttentionDifficulty Learning New ThingsDifficulty UnderstandingDifficulty Remembering ThingsRe-reading Things to Understand ItAngerDifficulty Making DecisionsChange in Sexual FunctioningReduced ConfidenceHelplessnessApathy (Don’t Care)IrritableChange in Sense of Taste or SmellFlashbacks to AccidentImpatienceFrustrationHearing ProblemsDifficulty Planning or Organizing

“Clunk” Sound with Neck MovementsNeck PainUpper Back PainLow Back PainShoulder PainUpper Arm PainElbow PainForearm PainWrist PainHand PainHip PainUpper Leg PainKnee PainLower Leg PainAnkle PainFoot PainJaw PainClicking in JawPain when ChewingFace PainChest PainStomach PainBruise/Contusion to ________________Abrasion/Scrape to_________________Other Symptom ___________________Other Symptom ___________________

Symptoms

Patient ___________________________ Date ____________ Date of Injury ___________

Please fill in all symptoms you currently have before the accident.that you did not have

C HBTInstitute.com

Brain/Neuropsych/MTBI SymptomsOrthopedic & Musculoskeletal Symptoms

Numb/Tingling Arm / Hand L RNumb/Tingling Leg / Foot L RWeakness Arm / Hand L RWeakness Leg / Foot L R

Range of Motion ProblemsHeadachesMuscle SpasmsDizzinessVisual DisturbancesSleep DisruptionRadiating PainAnxietyDepressionI am taking over-the-counter pain meds

Neurological Symptoms

Symptoms Associated with Injuries

Wanting to be Alone

Left RightLeft RightLeft RightLeft RightLeft RightLeft RightLeft RightLeft RightLeft RightLeft RightLeft RightLeft Right

Neck Area Consultation

Patient ______________________________ Today’s Date ___________ Date of Injury ____________

Please all areas on this picture where you haveshade in in the past 7 daysPAIN

Shade in in the past 7 daysall areas of ALTERED SENSATION ( )I.E. PINS/NEEDLES, NUMB, TINGLING

Shade in in the past 7 daysall areas of WEAKNESS, CLUMSINESS, DROPPING THINGS

Area Severity % of Time Sharp? Dull? Ache? Other?C4

C5

C6

C7

C8

T1

T2

T3

T4

Right

Right

Right

Right

Right

Right

Left

Left

Left

Left

Left

Left

Back

Back

Back

Front

Front

Front

Area Severity % of TimeC4

C5

C6

C7

C8

T1

T2

T3

T4

Pins/Needles? Numb? Tingling? Other?

Area Severity % of Time

C4

C5

C6

C7

C8

T1

T2

T3

T4

Weak Clumsy Drop Things Other

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I am having because of NECK PAIN in the past 7 days

Describe how NECK PAIN is affecting your normal daily activities

(Check all below that make your NECK hurt )

Laying on pillow Turning neck Looking UP Looking DOWN Combing Hair

Computer at Work Computer at Home Working Sports Driving

Others (please list other things that make your neck hurt)

(Check all below that make your NECK feel )

Doctor Treatments Helps for ______ Hours Days Weeks Months

Medications Helps for ______ Hours Days Weeks Months

Home Exercises Helps for ______ Hours Days Weeks Months

_________________ Helps for ______ Hours Days Weeks Months

_________________ Helps for ______ Hours Days Weeks Months

_________________ Helps for ______ Hours Days Weeks Months

FUNCTIONAL DIFFICULTIES

EXACERBATING FACTORS

ALLEVIATING FACTORS

more

better

Neck Area Consultation

Patient ______________________________ Today’s Date ___________ Date of Injury ____________

© 2010 HBTinstitute.com Page 2 of 2

Cervical Exam & Evaluation

I observed the following neck difficulties during the exam: Slow Movements Holding NeckTurning neck Tilting neck Nodding head Other _____________________________

I did did not observe abnormality of spine alignment today Single MultipleAssistive Devices are are not needed by this patient: __________________________

Compression for local pain on Rt Lt for Radicular Symptoms on Rt LtDistraction for local pain on Rt Lt for relief or Radicular Symptoms on Rt LtAsymmetrical ROM:Flex ______ Ext ______ Rt Lat ______ Lt Lat ______ Rt Rot ______ Lt Rot ______Other(s) ________________________________________________________________

Nerve Tension/Compression Signs: Spurling/Compression caused Anterolateral ShoulderArm Radiculopathy on the Rt LtMotor Deficit in Deltoid BicepsSensory Deficit in Anterolateral Shoulder Upper Arm on the Rt LtReflex Compromise Rt Biceps Decreased Increased Absent

Lt Biceps Decreased Increased AbsentAtrophy Present Rt ______“ Lt ______” measured mid-bicepsAOMSI Present at C4-5 Non-verified Verified by Stress X-rays DMX/FluoroscopyTranslation Instability of ______% Angular of ______Disc Herniation Present at C4-5 Non-verified Verified by MRI CT

Positive General Neck Tests

Motion Segment C4-5 (Nerve Root C5)

Motion Segment C5-6 (Nerve Root C6)Nerve Tension/Compression Signs: Spurling/Compression caused Lateral ForearmHand/Thumb Radiculopathy on the Rt LtMotor Deficit in Biceps Radial Wrist Extensors on the Rt LtSensory Deficit in Anterolateral Shoulder Upper Arm on the Rt LtReflex Compromise Rt Brachioradialis Decreased Increased Absent

Lt Brachioradialis Decreased Increased AbsentRt Pronator Teres Decreased Increased AbsentLt Pronator Teres Decreased Increased Absent

Atrophy Present Rt ______“ Lt ______” measured mid-forearmAOMSI Present at C5-6 Non-verified Verified by Stress X-rays DMX/FluoroscopyTranslation Instability of ______% Angular of ______Disc Herniation Present at C5-6 Non-verified Verified by MRI CT

Motion Segment C6-7 (Nerve Root C7)Nerve Tension/Compression Signs: Spurling/Compression caused Middle FingerRadiculopathy on the Rt LtMotor Deficit in Wrist Flexors Triceps Finger Extensors Ulnar Wrist Extensorson the Rt LtSensory Deficit in Middle Finger on the Rt LtReflex Compromise Triceps Decreased Increased AbsentAtrophy Present Rt ______“ Lt ______” measured mid-TricepsAOMSI Present at C6-7 Non-verified Verified by Stress X-rays DMX/FluoroscopyTranslation Instability of ______% Angular of ______Disc Herniation Present at C6-7 Non-verified Verified by MRI CT

Patient ____________________________ Today’s Date ___________ Date of Injury ____________

Page 1 of 2

Cervical Exam & Evaluation Neck

This injury was caused by _____________________________________________________of Neck Impairment is is not necessary.

Date of other neck injury for apportionment purposes _______________________________: No Objective Findings Mild Moderate Severe Very Severe

I reviewed the following: Prior Medical Records X-Ray Films X-Ray ReportsCT Films CT Reports MRI Films MRI ReportsDMX Films DMX Reports EMG/NCV ReportsLab Results Other _____________________

New Clinical Studies performed today and considered in this evaluation:Neck X-ray films CT MRI EMG/NCV Lab Work Other ________________

I did did Not find inconsistencies between previous records and my exam findingsI did did Not find inconsistencies between patient’s complaints and exam findingsI did did Not find inconsistencies between my observations, history, and/or examI did did Not findinconsistencies between symptoms reported and clinical studiesIn my opinion, the reliability of exam findings today is ______ %In my opinion, the reliability of clinical studies correlation with symptoms reported is ______%In my opinion, the reliability of clinical studies correlation with exam findings is ______%In my opinion, the reliability of imaging reports compared to actual images is ______%I did did not examine and evaluate other areas of the spine todayThis patient’s neck has has not reached Maximum Medical Improvement (MMI) todayContributions of Spine Areas to Functional Disability todayCervical ______% Thoracic ______% Lumbar ______% Pelvis ______%

for this patient’s Cervical Spine todayNon-specific chronic, or chronic recurrent spine painIVD & Motion Segment Pathology Single level Multiple levelsStenosisSpine Fracture(s) or Dislocation(s)

Apportionment

Impairment Class

Basic Diagnosis Categories

Motion Segment C7-T1 (Nerve Root T1)

Nerve Tension/Compression Signs: Spurling/Compression caused Medial ForearmHand (4th & 5th Fingers) Radiculopathy on the Rt LtMotor Deficit in Finger Flexors Hand Intrinsics on the Rt LtSensory Deficit in Medical Forearm 4th Finger 5th Finger on the Rt LtAtrophy Present Rt ______“ Lt ______” measured mid-forearmTranslation Instability of ______% Angular of ______Disc Herniation present at C7-T1 Non-verified Verified by MRI CT

Motion Segment T1-2 (Nerve Root T2)

Nerve Tension/Compression Signs: Spurling/Compression caused Medial ForearmRadiculopathy on the Rt LtMotor Deficit in Hand Intrinsics on the Rt LtSensory Deficit in Medial Forearm on the Rt LtTranslation Instability of ______% Angular of ______Disc Herniation present at T1-T2 Non-verified Verified by MRI CT

Signature of Doctor

© 2010 www.HBTinstitute.com Page 2 of 2

Patient __________________________ Today’s Date __________ Date of Injury __________

Upper Back Area Consultation

Patient ______________________________ Today’s Date ___________ Date of Injury ____________

Please all areas on this picture where you haveshade in in the past 7 daysPAIN

Shade in in the past 7 daysall areas of ALTERED SENSATION ( )I.E. PINS/NEEDLES, NUMB, TINGLING

Area Severity % of Time Sharp? Dull? Ache? Other?T2

T3

T4

T5

T6

T7

T8

T9

T10

Area Severity % of TimeT2

T3

T4

T5

T6

T7

T8

T9

T10

Pins/Needles? Numb? Tingling? Other?

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Back Side

Back Side

Front Side

Front Side

I am having because of UPPER BACK PAIN in the past 7 days

Describe how UPPER BACK PAIN is affecting your normal daily activities

(Check all below that make your UPPER BACK hurt )

Laying in Bed Sitting Bending Twisting Dressing

Computer at Work Computer at Home Working Sports Driving

Others (please list other things that make your UPPER BACK hurt)

(Check all below that make your UPPER BACK feel )

In-Office Treatments Helps for ______ Hours Days Weeks Months

Medications Helps for ______ Hours Days Weeks Months

Home Exercises Helps for ______ Hours Days Weeks Months

_________________ Helps for ______ Hours Days Weeks Months

_________________ Helps for ______ Hours Days Weeks Months

FUNCTIONAL DIFFICULTIES

EXACERBATING FACTORS

ALLEVIATING FACTORS

more

better

Right

Right

Right

Right

Left

Left

Left

Left

Low Back & Pelvis Area Consultation

Patient ______________________________ Today’s Date ___________ Date of Injury ____________

Please all areas on this picture where you haveshade in in the past 7 daysPAIN

Shade in in the past 7 daysall areas of ALTERED SENSATION ( )I.E. PINS/NEEDLES, NUMB, TINGLING

In my Low Back or Legs, WEAKNESS, STUMBLING, BUMPING INTO THINGS in the past 7 days

Area Severity % of Time Sharp? Dull? Ache? Other?

T11

T12

L1

L2

L3

L4

L5

S1

S2-5

Area Severity % of Time

T11

T12

L1

L2

L3

L4

L5

S1

S2-5

Pins/Needles? Numb? Tingling? Other?

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I am having because of LOW BACK PAIN in the past 7 days

Describe how LOW BACK PAIN is affecting your normal daily activities

(Check all below that make your LOW BACK hurt )

Laying in Bed Sitting Bending Twisting Lifting Pushing/Pulling

Computer at Work Computer at Home Working Sports Driving

Others (please list other things that make your LOW BACK hurt)

(Check all below that make your LOW BACK feel )

In-Office Treatments Helps for ______ Hours Days Weeks Months

Medications Helps for ______ Hours Days Weeks Months

Home Exercises Helps for ______ Hours Days Weeks Months

_________________ Helps for ______ Hours Days Weeks Months

_________________ Helps for ______ Hours Days Weeks Months

FUNCTIONAL DIFFICULTIES

EXACERBATING FACTORS

ALLEVIATING FACTORS

more

better

Right

LeftLeft

Right

LeftLeft

Back Exam & Evaluation

I observed the following neck difficulties during the exam: Slow Movements SittingRising from Sitting to Standing Lowering from Standing to Sitting Other _____________

I did did not observe gross abnormality of spine alignment today Single MultipleAssistive Devices are are not needed by this patient: __________________________

Soto Hall reproduced Thoracic Pain at (circle)T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12Palpation elicited tenderness atPalpation revealed objective spasm(s) atSensory Deficits confirmed in dermatomesSensory Deficits include sharp/dull light touch hot/cold other ________

Kemp’s Test reproduced local facet pain at T12-L1 L1-2 L2-3 L3-4 L4-5 L5-S1 on Rt Lt

Motor Deficit in QuadricepsSensory Deficit in Anterior Thigh Anterior Knee Medial leg/foot on the Rt LtReflex Compromise Rt Patella Decreased Increased Absent

Lt Patella Decreased Increased AbsentAtrophy Present Rt ______“ Lt ______” measured mid-thighAOMSI Present at L3-4 Non-verified Verified by Stress X-rays DMX/FluoroTranslation Instability of _____ mm Angular of ______Disc Herniation Present at L3-4 Non-verified Verified by MRI CT

Positive General UPPER Back Tests

Positive General LOW Back Tests

Motion Segment L3-4 (Nerve Root L4)

T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12

Milgram’s Test reproduced back pain at T12-L1 L1-2 L2-3 L3-4 L4-5 L5-S1Palpation elicited tenderness at T12-L1 L1-2 L2-3 L3-4 L4-5 L5-S1 on Rt LtPalpation revealed objective spasm(s) at T12-L1 L1-2 L2-3 L3-4 L4-5 L5-S1 on Rt Lt

Kemp’s Test reproduced radicular symptoms at T12-L1 L1-2 L2-3 L3-4 L4-5 L5-S1 on Rt LtPositive Straight Leg Raisereproduced radicular pain at 35-70 degrees other ____Braggard’s Test confirmed and reproduced SLR radiculopathy on the Rt Lt

FABERE test reproduced joint pain at Lt SI Rt SI Lt Hip Rt HipPalpation elicited tenderness at over sacrum Rt Lt sciatic notch Rt Lt

peritrochanter Rt Lt other ___________________________________________Palpation revealed spasm(s) over sacrum Rt Lt sciatic notch Rt Lt

peritrochanter Rt Lt other ___________________________________________

Motor Deficit in extensor hallucis longus on the Rt LtSensory Deficit in lateral thigh anterolateral leg mid-dorsal foot on the Rt LtReflex Compromise Rt medial hamstrings Decreased Increased Absent

Lt medial hamstrings Decreased Increased AbsentAtrophy Present Rt ______“ Lt ______” measured mid-calfAOMSI Present at L4-5 Non-verified Verified by Stress X-rays DMX/FluoroTranslation Instability of ______ mm Angular of ______Disc Herniation Present at L4-5 Non-verified Verified by MRI CT

Positive Nerve Stretch/Compression Tests

Positive General Pelvis Tests

Motion Segment L4-5 (Nerve Root L5)

Patient ____________________________ Today’s Date ___________ Date of Injury ____________Area(s) examined today Upper Back Low Back Pelvis

Page 1 of 2© 2010 www.HBTinstitute.com

Back Exam & Evaluation

This injury(s) was caused by ___________________________________________________of Upper Back Impairment is is not necessary.

Apportionment of Lower Back Impairment is is not necessary.Apportionment of Pelvis Impairment is is not necessary.Date of other injury(s) for apportionment purposes __________________________________

:Upper Back: No Objective Findings Mild Moderate Severe Very SevereLower

I reviewed the following: Prior Medical Records X-Ray Films X-Ray ReportsCT Films CT Reports MRI Films MRI ReportsDMX Films DMX Reports EMG/NCV ReportsLab Results Other __________________________________

New Clinical Studies performed today and considered in this evaluation:Neck X-ray films CT MRI EMG/NCV Lab Work Other ________________

I did did Not find inconsistencies between previous records and my exam findingsI did did Not find inconsistencies between patient’s complaints and exam findingsI did did Not find inconsistencies between my observations, history, and/or examI did did Not findinconsistencies between symptoms reported and clinical studiesIn my opinion, the reliability of exam findings today is ______ %In my opinion, the reliability of clinical studies correlation with symptoms reported is ______%In my opinion, the reliability of clinical studies correlation with exam findings is ______%In my opinion, the reliability of imaging reports compared to actual images is ______%I did did not examine and evaluate other areas of the spine todayBody Area(s) Maximum Medically Improved (MMI) today Upper Back Low Back PelvisContributions of Spine Areas to Functional Disability todayCervical ______% Thoracic ______% Lumbar ______% Pelvis ______%

Upper Back Non-specific chronic, or chronic recurrent spine painIVD & Motion Segment Pathology Single level Multiple levelsStenosis Spine Fracture(s) or Dislocation(s)

Lower

Apportionment

Impairment Class

Basic Diagnosis Categories (if MMI today)

Back: No Objective Findings Mild Moderate Severe Very SeverePelvis: No Objective Findings Mild Moderate Severe Very Severe

Back Non-specific chronic, or chronic recurrent spine painIVD & Motion Segment Pathology Single level Multiple levelsStenosis Spine Fracture(s) or Dislocation(s)

Pelvis Non-specific chronic, or chronic recurrent spine painIVD & Motion Segment Pathology Single level Multiple levelsStenosis Spine Fracture(s) or Dislocation(s)

Motion Segment L5-S1 (Nerve Root S1)

Motor Deficit in ankle plantar flexors on the Rt LtSensory Deficit in posterior leg lateral foot on the Rt LtAtrophy Present Rt ______“ Lt ______” measured mid-calfTranslation Instability of ______mm Angular of ______Disc Herniation present at L5-S1 Non-verified Verified by MRI CT

Signature of Doctor© 2010 www.HBTinstitute.com Page 2 of 2

Time spent face to face with patient today was _____ minutes

Diagnosis for ____________________________________________ Date of Injury: ___________________

Diagnosis Status: Initial Update Date of Diagnosis: ___________________

Pelvis/Hip/Sacrum

Cervical Spine Injuries Thoracic Spine Injuries Lumbar Spine Injuries

Upper Extremity Injuries Lower Extremity Injuries

Abrasions

Contusions

MISC.

C HBTInstitute.com 2008

847.0 Cervical Sp/St839.00 Cervical Sublux. Unspecified839.08 Multiple Cervical Sublux.

723.3 Cervicobrachial Nerve Injury

728.4 Cerv. Ligt. Laxity728.5 Cerv. Hypermobility720.1 Cerv. Enthesopathy723.1 Cervicalgia728.85 Cerv. Myospasm729.1 Cervical Myalgia737.29 Loss of Cerv. Lordosis737.19 Traumatic Cerv. Kyphosis738.2 Acquired Cerv. Deformity722.0 Cerv. Disk Herniation/Neuritis953.0 Cerv. Nerve Injury

782.0 Cerv. Sensation Disturbance728.2 Upper Extremity Atrophy728.9 Upper Extremity Weakness722.4 Cervical DJD/DDD722.81 Post Cervical Laminectomy

847.1 Thoracic Sp/St839.21 Thoracic Subluxation

786.50 Chest Pain

728.4 Thor. Ligt. Laxity728.5 Thor. Hypermobility720.1 Thor. Enthesopathy724.1 Thoracalgia728.85 Thoracic Myospasm729.1 Thoracic Myalgia848.3 Ribs Sprain/Strain839.8 Rib Cage Subluxation848.41 Sternoclavicular Sp/St

722.11 Thor. Disc Herniation853.1 Thor. Nerve Injury724.4 Thoracic Neuritis953.4 Brachial Plex. Nerve Inj.353.0 Brachial Plexus Lesion722.51 Thoracic DJD/DDD

.724.2 Lumbago

729.1 Lumbar Myalgia722.10 Lumbar Disk Herniation953.2 Lumbar Nerve Injury724.4 Lumbar Neuritis

722.52 Lumb DJD/DDD722.83 Post Laminectomy756.12 Spondylolisthesis719.7 Difficulty Walking

728.85 Lumb. Myospasm

782.0 Sensation Disturbance728.2 Leg Atrophy728.9 Leg Muscle Weakness729.5 Leg Limb Pain729.81 Leg Swelling

839.8 Upper Extremity Subluxation728.85 Upper Extremity Myospasm729.81 Upper Extremity Swelling729.5 Upper Extremity Tissue Pain840.9 Shoulder Sprain/Strain719.40 UE Joint Pain - 1 Joint719.49 UE Joint Pain - Mult. Joints726.10 Shoulder Enthesopathy841.9 Elbow Sprain/Strain839.8 Elbow Subluxation726.3 Elbow Enthesopathy842.00 Wrist Sprain/Strain839.8 Wrist Subluxation726.4 Wrist Enthesopathy842.10 Hand Sprain/Strain839.8 Hand Subluxation

839.8 Lower Extremity Subluxation728.85 Lower Extremity Myospasm719.40 LE Joint Pain - 1 Joint719.49 LE Joint Pain - Mult. Joints729.81 Lower Extremity Swelling729.5 Lower Extremity Tissue Pain843.9 Hip/Thigh Sprain/Strain726.5 Hip Region Enthesopathy844.9 Knee Sprain/Strain726.6 Knee Enthesopathy845.00 Ankle Sprain/Strain726.7 Ankle/Foot Enthesopathy845.10 Foot Sprain/Strain719.7 Difficulty Walking

910.0 Face, Neck, Head911.0 Abdomen, Torso912.0 Shoulder & Arm913.0 Elbow, Arm, Wrist914.0 Hand & Fingers916.0 Hip/Thigh/Leg/Ankle917.0 Foot & Toes

920.0 Face, Neck, Head922 Abdomen, Torso923.0 Shoulder & Arm923.1 Elbow, Arm, Wrist923.2 Hand & Fingers924.0 Hip/Thigh/Leg/Ankle924.2 Foot & Toes

MISCBrain Injuries

847.2 Lumbar Sp/St839.20 Lumbar Subluxation728.4 Lumb.Ligt.Laxity728.5 Lumb.Hypermobility720.1 Lumb. Enthesopathy

Total Partial Limitations ________________________________________

846.9 Sacroiliac Sp/St839.42 Sacroiliac Sublux.847.3 Sacrum Sp/St724.6 Sacrum Instability847.4 Coccyx Sp/St839.69 Hip/Pelvis Sublux.724.3 Sciatic Neuritis956.0 Sciatic NI953.3 Sacral NI

850.0 Concussion/No LOC850.1 Concussion/Brief LOC850.2 Concussion Mod. LOC854.00 Traumatic Brain Injury907.0 Late FX of Brain Injury784.0 Headache780.5 Sleep Disturbance780.54 Hypersomnolence780.7 Fatigue/Lethargy/Tired787.0 Nausea/Vomithing780.4 Dizzy/Lightheaded386.11 Positional VertigoOther ___________________

308.0 Anxiety300.4 Depression309.81 Post Traumatic Stress Disorder848.1 TMJ Sp/St524.60 TMJ Pain728.85 TMJ Myospasm388.31 Tinnitus401.1 Hypertension250.0 Aggravation of Diabetes781.9 Abnormal Posture 2ary to Trauma788.30 Urinary IncontinenceOther(s)__________________________Disability to_______________________

TREATMENT PLAN

Patient _________________________________ Today’s Date _____________ DOI _____________

______________________________The following recommended treatments are to be done through

C HBTInstitute.com

Cervical Spine Tx Thoracic Spine Tx

Upper Extremity Tx Lower Extremity Tx

Depression/Anxiety Plan TMJ Plan

Misc Plans

Brain Injury Plan

Lumbar Spine Tx

Pelvis/Hip/Sacrum Tx

98940(1)(2) Chiropractic Manip.97124 Massage ____ minutes97035 Ultrasound ____ minutes97014 97032 Electric Stim.97012 Mechanical Traction97140 Myofascial Release97110 Ther.Exer. 1on1 ____min97150 Ther.Exer.Group ____minOfficeHome Neck ExercisesHHome Ice PackHome Cervical Traction PillowBed RestHome Other _______________Gym Neck Exercises/ActivityMD CT MRI DMX

ome Cervical Stabilization Collar

Other ________________

98940(1)(2) Chiropractic Manip.97124 Massage ____ minutes97035 Ultrasound ____ minutes97014 97032 Electric Stim.97012 Mechanical Traction97140 Myofascial Release97110 Ther.Exer. 1on1 ____min97150 Ther.Exer.Group ____minOffice

Home Upper Back ExercisesHome Ice PackBed RestHome Other ________________Gym Thoracic Exercises/ActivityMD CT MRI DMX

Other ________________Office Other ________________Home Thoracic Traction Pillow

98940(1)(2) Chiropractic Manip.97124 Massage ____ minutes97035 Ultrasound ____ minutes97014 97032 Electric Stim.97012 Mechanical Traction97140 Myofascial Release97110 Ther.Exer. 1on1 ____min97150 Ther.Exer.Group ____minOfficeHome Low Back ExercisesHome Ice PackHome Lumbar Stabilization BeltHome Lumbar Traction PillowBed RestHome Other ________________Gym Lumbar Exercises/ActivityMD CT MRI DMX

Other ________________

98940(1)(2) Chiropractic Manip.97124 Massage ____ minutes97035 Ultrasound ____ minutes97014 97032 Electric Stim.97012 Mechanical Traction97140 Myofascial Release97110 Ther.Exer. 1on1 ____min97150 Ther.Exer.Group ____min97116 Gait Training/Stair Climb

Home Pelvis/Sacrum ExercisesHome Ice PackBed RestGym Pelvis/Sacrum ExercisesMD MRI CT ______

Office Other _______________

98943 Chiropractic Manip.97124 Massage ____ minutes97035 Ultrasound ____ minutes97014 Elect.Stim (unattended)97032 Elect.Stim (attended)97140 Myofascial Release97110 Ther.Exer. 1on1 ____min97150 Ther.Exer.Group ____min97116 Gait Training/Stair Climb

Home Lower Extremity ExercisesHome Ice PackBed RestGym Lower Extremity ExercisesMD MRI CT ______

Office Other _______________

98943 Chiropractic Manip.97124 Massage ____ minutes97035 Ultrasound ____ minutes97014 Elect.Stim (unattended)97032 Elect.Stim (attended)97140 Myofascial Release97110 Ther.Exer. 1on1 ____min97150 Ther.Exer.Group ____minOffice Other ________________

Home Upper Extremity ExercisesHome Ice PackBed RestGym Upper Extremity ExercisesMD MRI CT ______

Office Other ________________

90801 Cognitive Consultation96118 Cognitive Screening90801 Hypersomnolence Consultation96118 Hypersomnolence Evaluation97532 Cognitive Training In Office _____ min.Home Physical ExerciseHome MeditationHome Cognitive Rehabilitation ExercisesMD ReferralCounselingPolysomnogramAvoid Stressful ActivitiesBed RestOther _______________________________

PhysiotherapyMassage TherapySplint for Home UseHome TMJ ExercisesRestricted TMJ ActivityRelaxation ExercisesSoft Food/Liquid DietDDS Referral

ExerciseMeditationCounselingAvoid Stressful ActivitiesNatural Anti-DepressantsNatural Anti-AnxietyBed RestMD Referral

Home TENS Natural Pain RelieversCane/Crutches/Orthotics Order Impairment RatingNatural Anti-Inflammatories Re-evaluate in _____ days

____ Office Treatments per _______

____ Home Treatments per _______