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Student Adjusting Form for Full Spine

Student Adjusting Form for Full Spine - Pos Neg Balanced...

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Technique Adjusting Notes Patient Name: Patient History - Include any cautions or contraindications; continue on back of form if space is insufficient: Visualization: Cervical: Head tilt L R None Head rotation L R None Ant head translation Yes No Thoracic: High Shoulder L R None Scapula Out L R None Skin Fold Asymmetry L R None Lumbar: Stacking L R None Pelvic: High Hip L R None Wide gluteal L R None Lower Extremity: Genu Varus Yes No Genu Valgum Yes No Toe: Out In L R None Instrumentation: Atlas Fossa Reading: L R Nervoscope Level Amplitude/Direction Other: Static Palpation: Motion Palpation: Leg Check - prone: Short L R Amount _____ Even Derifield Cervical: L R Bilat None Derifield Pelvic:
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Unformatted text preview: Pos Neg Balanced Fluid Motion: L R Sacral leg check: L R Neg Supine Leg Check: Short L R Amount _____ Even X-ray Listings : Leg AD: L_____ R_____ None X-rays Date: Occiput: Atlas: Lower Cervical: Thoracic: Lumbar: Ilium: L_____ R_____ Sacrum: Assessment: Recommendations: Adjustment: Segment Listing Technique Post Checks: I understand that care is not being provided, but the adjustment is being performed in a classroom setting strictly as a learning experience and with potentially incomplete work-up. It is not the intention of this encounter to be therapeutic. Patient: Date: Student Doctor: Date: Observing Doctor: Date:...
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