NOTE Client Name: Date: SUBJECTIVE: (Client presents with and complains of): q Sharp Pain q Dull Ache q Numbness q Tingling q Burning q Shooting q Throbbing Other / Notes: These complaints are noted in the client’s: q Neck q Shoulders q Upper Arms q Lower Arms q Upper Back q Sides q Chest q Abdomen q Groin q Lower Back q Buttocks q Upper Legs q Lower Legs Other / Notes: v OBJECTIVE: (Found during the course of evaluation and treatment): E L P M A q Pain q Tenderness q Muscle Spasm q Trigger Points q i / h Muscle Tone q i / h ROM q i / h Muscle Texture Other / Notes: S These findings are noted in the client’s: q Neck q Shoulders q Upper Arms q Lower Arms q Upper Back q Sides q Chest q Abdomen q Groin q Lower Back q Buttocks q Upper Legs q Lower Legs Other / Notes: v ASSESSMENT: (Your opinion of the client’s condition): q Muscle Spasm q Neck Pain q Thoracic Pain q Lumbar Pain q Arm Pain q Leg Pain q Chest Pain Other / Notes: The client is: q Improving q Staying the Same q Getting Worse q N/A – First Visit Client prognosis is: q Excellent q Very Goo
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