Subjective

Presenting complaint and history:

Past medical and lifestyle history:

Pain Score

On a scale of 0 to 10, with 0 being no pain and 10 being the worst pain imaginable, how would you rate your pain right now?

012345678910

Pain context

Body site

Search Body site

Laterality

Select laterality...

Pain context

Current

Related condition

Search Related condition

Status

Active

Notes

Document quality, relief factors, and aggravating factors...

Red flags screened (check if present):

Unexplained weight loss or night pain

Neurological deficit

Cardiopulmonary or visceral symptoms

Recent trauma

Inflammatory pattern

Objective

Postural and global observation:

Regional Motion Screen

Region	Findings	Restriction
Cervical
Thoracic
Lumbar
Pelvis / sacrum
Lower limb
Upper limb

Special and neurological testing:

Assessment

Diagnosis Search

Diagnosis

Coding Details

Status

Active

Severity

Select severity...

Onset Date

YYYY-MM-DD

Resolved Date

YYYY-MM-DD

Working diagnosis and prognosis:

Plan

Planned approach (check all):

Soft tissue / myofascial techniques

Articulatory / mobilization

Muscle energy / counterstrain

Manipulation as indicated

Exercise / self-management

Referral or imaging if indicated

Management plan and follow-up:

Subjective

Pain NRS

Objective

Regional Motion Screen

Assessment

Diagnosis Snapshot

Plan

Osteopathy Initial Consultation

Preview