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DAILY NOTES

Patient Name:___________________________________________________ Date:_____________________________ Acct.#:__________________ SUBJECTIVE: [S + SYNDROME

LETTER

+ IMPROVEMENT LETTER + PAIN LEVEL (OPTIONAL)] Pain Level: 1-Minimal2-Slight3-Moderate4-Severe5-V/SevereAnnoying, forgotten w/activity Tolerable, may interfere w/activity Modification of activity/not disabling Unable to perform normal duties Causes patient to cry out in pain

PATIENT TO RETURN: [P + CODE] RE12 = As symptoms demand 1D 2D 3D 4D 5D 6D = = = = = = in in in in in in 1 2 3 4 5 6 day days days days days days 1W = in 1 week 2W = in 2 weeks 3W = in 3 weeks 1M = in 1 month 2M = in 2 months 3M = in 3 months

Syndrome: [A] Cervical [B] Headache [C] Shoulder/ Arm [D] Tho. Intercostal [E] Tho. Back Muscle [F] Lumbar [G] Lumbar Pelvic [H] Lumbar Leg [ ] [ ] [ ] [ ]

Improvement: [G] Greatly Improved [ I ] Improving [S] Same [W] Worse [E] Exacerbation [R] Resolved [ ] [ ] [ ] [ ] [ ] [ ]

TREATMENT: [T + TRTMT LETTER + (WRITE IN AREA TREATED)] [M] [F] [CT] [D] [C] [MM] [U] [MT] [E] [ ] [ ] [ ] [ ] [ ] [ ] Manipulation Fomentation Manual Cox Diathermy Cryotherapy Manual Massage Ultrasound Mechanical Traction Elec. Muscle Stimulation

OBJECTIVE: RANGE OF MOTION = [O + AREA + R.O.M. + DIRECTION] MUSCLE SPASM = [O + AREA + DIRECTION] = [O + AREA + DIRECTION + VERTEBRA] FACET/FIXATION Area: [C] Cervical [T] Thoracic [L] Lumbar [P] Pelvic R.O.M.: [L] Lat Flex [R] Rotation [F] Flexion [EX] Extension Direction: [R] Right [L] Left [B] Bi/Lat Vertebra: [O] Occiput [1] thru [12] [S] Sacrum [ I] Ilium

ASSESSMENT: [A + LETTER + NUMBER] [A] Progressing as anticipated [B] Progressing slowly but steadily [C] Progressing slower than anticipated [D] Progressing rapidly [E] Progressing faster than anticipated [F] Making no measurable progress [ ] [ ] [ ] [ ]

Resolved Better Same* Worse

0

1-2-3-4-5-6-7-8-9

10* 11-12-13-14-15

*10 = Condition at Initial Visit

USE CODE ONLY, NO AREA: [MA] Medicare Adjustment [MF] Manipulation Obj. Findings + Area:

Date: _____________

Subjective: #____________ #____________ #____________ #____________ Exacerbation [ ] Note [ ]

Objective: #____________ #____________ #____________ #____________ #____________ Objective: #____________ #____________ #____________ #____________ #____________ Objective: #____________ #____________ #____________ #____________ #____________ Objective: #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________

Assessment: #____________ Return in: #____________

Treatment:

#_________ area _______________________ #_________ area _______________________ #_________ area _______________________ #_________ area _______________________ #_________ area _______________________

Date: _____________

Subjective: #____________ #____________ #____________ #____________ Exacerbation [ ] Note [ ]

Assessment: #____________ Return in: #____________

Treatment:

+

Area:

#_________ area _______________________ #_________ area _______________________ #_________ area _______________________ #_________ area _______________________ #_________ area _______________________

Date: _____________

Subjective: #____________ #____________ #____________ #____________ Exacerbation [ ] Note [ ]

Assessment: #____________ Return in: #____________

Treatment:

+

Area:

#_________ area _______________________ #_________ area _______________________ #_________ area _______________________ #_________ area _______________________ #_________ area _______________________

Date: _____________

Subjective: #____________ #____________ #____________ #____________ Exacerbation [ ] Note [ ]

Assessment: #____________ Return in: #____________

Treatment:

+

Area:

#_________ area _______________________ #_________ area _______________________ #_________ area _______________________ #_________ area _______________________ #_________ area _______________________

Date: _____________

Subjective: #____________ #____________ #____________ #____________ Exacerbation [ ] Note [ ]

Objective: #____________ #____________ #____________ #____________ #____________ Objective: #____________ #____________ #____________ #____________ #____________ Objective: #____________ #____________ #____________ #____________ #____________ Objective: #____________ #____________ #____________ #____________ #____________ Objective: #____________ #____________ #____________ #____________ #____________ Objective: #____________ #____________ #____________ #____________ #____________ Objective: #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________ #____________

Assessment: #____________ Return in: #____________

Treatment:

+

Area:

#_________ area _______________________ #_________ area _______________________ #_________ area _______________________ #_________ area _______________________ #_________ area _______________________

Date: _____________

Subjective: #____________ #____________ #____________ #____________ Exacerbation [ ] Note [ ]

Assessment: #____________ Return in: #____________

Treatment:

+

Area:

#_________ area _______________________ #_________ area _______________________ #_________ area _______________________ #_________ area _______________________ #_________ area _______________________

Date: _____________

Subjective: #____________ #____________ #____________ #____________ Exacerbation [ ] Note [ ]

Assessment: #____________ Return in: #____________

Treatment:

+

Area:

#_________ area _______________________ #_________ area _______________________ #_________ area _______________________ #_________ area _______________________ #_________ area _______________________

Date: _____________

Subjective: #____________ #____________ #____________ #____________ Exacerbation [ ] Note [ ]

Assessment: #____________ Return in: #____________

Treatment:

+

Area:

#_________ area _______________________ #_________ area _______________________ #_________ area _______________________ #_________ area _______________________ #_________ area _______________________

Date: _____________

Subjective: #____________ #____________ #____________ #____________ Exacerbation [ ] Note [ ]

Assessment: #____________ Return in: #____________

Treatment:

+

Area:

#_________ area _______________________ #_________ area _______________________ #_________ area _______________________ #_________ area _______________________ #_________ area _______________________

Date: _____________

Subjective: #____________ #____________ #____________ #____________ Exacerbation [ ] Note [ ]

Assessment: #____________ Return in: #____________

Treatment:

+

Area:

#_________ area _______________________ #_________ area _______________________ #_________ area _______________________ #_________ area _______________________ #_________ area _______________________

Date: _____________

Subjective: #____________ #____________ #____________ #____________ Exacerbation [ ] Note [ ]

Assessment: #____________ Return in: #____________

Treatment:

+

Area:

#_________ area _______________________ #_________ area _______________________ #_________ area _______________________ #_________ area _______________________ #_________ area _______________________

INITIALEXAMINA TION

Patient Name:___________________________________________________ Date:_____________________________ Acct.#:__________________ GENERAL IMPRESSION [ I (INITIAL EXAM) + G (GENERAL IMPRESSION) + CODE] Appear: (IG01) [ ] Stated Age [ ] Older [ ] Younger Build: (IG02) [ ] Slight [ ] Average [ ] Heavy Gait: (IG03) [ ] Antalgic [ ] Normal [ ] Congenital [ ] Protective [ ] Not observed [ ] Neurologically Disturbed Minor's Sign: (IG04) [ ] Negative [ ] Positive [ ] Rt [ ] Lt [ ] Both Sides Libman: (IG05) [ ] Normal [ ] Low [ ] High Height: Weight: Temp.: Pulse: __________ (IG06) __________ (IG07) __________ (IG08) __________ (IG09)

PHYSICAL EXAMINATION [ I (INITIAL EXAM) + CODE] Blood Pressure: Lt ________/________ (IBP01) Rt ________/________ (IBP02) Lying ________/________ (IBP03) Standing ________/________ (IBP04) Measurements (Circumferential): (IMC01) Chest: Ins. _______ Exp. _______ Diff. _______ (IMA01) Arm: Biceps Lt __________ Rt __________ (IMA02) Forearm Lt __________ Rt __________ (IML01) Leg: Thigh Lt __________ Rt __________ (IML02) Calf Lt __________ Rt __________ CERVICAL EXAMINATION Cervical Muscle Palpation: R=Right L=Left B=Bilateral [ ] Palpation (IF004) Cervical Facet: [ ] Pos Rt (IC037) [ ] Pos Lt (IC038) [ ] Bi/Lat (IC039) [ ] Level __________ Neck Pain: R=Right L=Left B=Bilateral [ ] Cervical Compression (IF001) [ ] Max. Cerv. Compr. (IF002) Present [ ] Bakody S. (IAC01) Positive [ ] Distraction T. (IFF13) Positive [ ] Valsalva M. (IC013) Positive [ ] Soto-Hall (IC011) Positive [ ] Dejerine Triad (IAC08) Cervical Percussion: [ ] Sprain Level __________ (IFF08) [ ] Strain (If not sprain) (IFF07) Motion With Pain: [ ] Increased pain opposite lat. flex & rot. (IFF04) [ ] Increased pain side of lat. flex & rot. (IFF05) [ ] Both above positive (IFF06) Cervical Motion Studies: Norm Exam Flex. 45 ______ Ext. 45 ______ R.Lat.Flex 45 ______ L.Lat.Flex 45 ______ R.Rot. 80 ______ L.Rot. 80 ______ Muscle Testing Via Hand Dynamometer: (IC048) Right hand 1st______lbs. 2nd______lbs. 3rd______lbs. Left hand 1st______lbs. 2nd______lbs. 3rd______lbs. Shoulder/Arm/Hand Pain (R=Right L=Left): [ ] Adson/Scalene M. (IF006) [ ] Wright's Test (IAC04) [ ] Costoclavicular M. (IAC02) [ ] Phalen's Test (IAC05) [ ] Allen's Test, radial artery (IAC03) [ ]Allen's Test, ulnar artery (IAC10) Muscle Strength: Level Muscle C5 Deltoid C5-C6 Biceps C6 Wrist extensors C7 Wrist flexors C8 Finger flexors T1 Finger abductors x = N (Normal), A=Abnormal Head [ ] (IPH1x) Thorax [ ] (IPH4x) Eye [ ] (IPH2x) Abdomen [ ] (IPH5x) ENT [ ] (IPH3x) Heart [ ] (IPH6x) Details:________________________________ ______________________________________

Pain [ ] (ICA02) [ ] (ICB02) [ ] (ICC02) [ ] (ICD02) [ ] (ICE02) [ ] (ICF02)

R=Right L=Left [ ] (IF007) [ ] (IF008) [ ] (IF009) [ ] (IF010) [ ] (IF011) [ ] (IF013)

THORACIC EXAMINATION Thoracic Muscle Palpation: R=Right L=Left B=Bilateral [ ] Palpation (IF014) Thoracic Percussion: [ ] Sprain Level _______ (IFF18) [ ] Strain (If not sprain) (IFF17) Thoracic Facet: [ ] Pos Rt (IT017) [ ] Pos Lt (IT018) [ ] Bi/Lat (IT019) [ ] Level ________ Beevor's Sign (R=Right L=Left): [ ] Positive (IF015) Soto-Hall: [ ] Positive (IT010)

Thoracic Spinous: [ ] Pain Level _______ (IFF19)

LUMBAR EXAMINATION Lumbar Muscle Palpation: R=Right L=Left B=Bilateral [ ] Palpation (IF016) Lumbar Facet: [ ] Pos Rt (IL115) [ ] Pos Lt (IL116) [ ] Bi/Lat (IL117) Level ________ Lumbar Percussion: [ ] Sprain Level _______ (IFF38) [ ] Strain (If not sprain) (IFF23) Dorso-Lumbar Studies: Pain Norm Exam [ ] Flex. 90 ______ [ ] Ext. 30 ______ [ ] L.Rot. 30 ______ [ ] R.Rot. 30 ______ [ ] L.Lat.Flex. 30 ______ [ ] R.Lat.Flex. 30 ______ Lumbar Test (R=Right L=Left): [ ] Straight Leg Raise (IFF24) [ ] Cox Sign (IFF26) [ ] Braggard (IF022) [ ] Gaenslen's (IF027) [ ] Fabere-Patrick (IF026) [ ] Popliteal Fossa Press (IZ002) [ ] Thompson Sacral (IF028) [ ] Kemp's Sign (IF033) [ ] Neri's Bowing (IF035) [ ] Pelvic Level (IF030) [ ] Bechterew Sitting (IF034) Lumbar Test (Positive): [ ] Laseque Rebound (IFF25) [ ] Heel Walk positive (IF031) [ ] Toe Walk positive (IF032) [ ] Homan's & Moses' Sign (IFF27) [ ] Prone Knee Flexion (IZ001) [ ] Well Leg Raise (IF020) [ ] Dejerine Triad (IAC09) [ ] Supported Adam (IAC06) Muscle Strength: Level Muscle R=Right L=Left L4 Tibialis Anterior [ ] (IF037) L5 Extensor Hall. Lg. [ ] (IF038) S1 Peroneus Lg.+B. [ ] (IF039)

Pain [ ] (ILA02) [ ] (ILB02) [ ] (ILF02) [ ] (ILE02) [ ] (ILD02) [ ] (ILC02)

NEUROLOGICAL EXAMINATION Reflex Status: Cer [ ] WNL (IF055) Deep (by Wexler 0 1+ 2+ 3+ 4+ 5+): Reflex Root Disc R=Right L=Left C5 C4-C5 ______ (IFF33) Biceps Triceps C6 C5-C6 ______ (IFF35) Brachioradialis C7 C6-C7 ______ (IFF34) Reflex Status: Lum [ ] WNL (IF056) Deep (by Wexler 0 1+ 2+ 3+ 4+ 5+): Reflex Root Disc R=Right L=Left Patellar L4 L3-L4 ______ (IFF36) Ankle S1 L5-S1 ______ (IFF37) Pathological Reflexes [ ] WNL (IF040) Dermatome: R-L-B [ ] Ankle Clones (IN035) [ ] Hypo (IFF31) [ ] Babinski (IF061) Level ____________ Coordination Test: [ ] WNL (IF041) Level ____________ [ ] Finger/Nose (IN028) [ ] Hyper (IFF32) [ ] Finger/Finger (IN029) Level ____________

X-RAYEXAMINA TION

Patient Name:___________________________________________________ Date:_____________________________ Acct.#:__________________

SEGMENTAL DYSFUNCTION OR SUBLUXATION [I (INITIAL EXAM) + XR (X-RAY) + CODE] [ ] Introduction to Subluxation & Segmental Dysfunctions (IXR01): [ ] Retrolisthesis (IXR02) Grade & Level _________________________ [ ] Spondylolisthesis (IXR03) Grade & Level _________________________ [ ] Flexion Malposition (IXR04) Level ________________________________ [ ] Lateral Listhesis (IXR05) Level ________________________________ [ ] Aberrant Motion (IXR06) Level ________________________________ [ ] Extension Malposition (IXR07) Level ________________________________ [ ] Lat. Flex. Malposition (IXR08) Level ________________________________ [ ] Rotational Malposition (IXR09) Level ________________________________ [ ] Hypermobility/Fixation (IXR10) Level _________________________ [ ] Hypermobility or Loosening (IXR11) Level _________________________ [ ] Foraminal Occlusion (IXR12) Level _________________________ [ ] Sacral-Pelvic Dysfunction (IXR42) Right __________ Left ___________ Disc Height Loss: [ ] Decreased Minimal (IXRD1) Level _________________________ [ ] Decreased Moderate (IXRD2) Level _________________________ [ ] Decreased Advanced (IXRD3) Level _________________________

[ ] Abnormal Findings Producing Chronicity (IXR13): Arthritis: [ ] Osteo: Level __________________________ [ ] Rheumatoid: Level _____________________ [ ] Facet Sclerosis: Level __________________ [ ] Infectious: Level _______________________ [ ] Inflammatory: Level ____________________ Disc Height: [ ] Decreased Minimal: Level _______________ [ ] Decreased Moderate: Level ______________ [ ] Decreased Advanced: Level ______________ [ ] Increased: Level _______________________ (IXR14) (IXR15) (IXR16) (IXR17) (IXR05) (IXRD1) (IXRD2) (IXRD3) (IXRD0) Vertebral Pathology: [ ] Ebernation: Level _________________________ [ ] Joints of Lushka Sclerosis: Level _______________________________ [ ] Osteoporosis: Level _______________________ [ ] Schmorls Nodes: Level ____________________ [ ] Blocked Vertebra: Level ____________________ [ ] Spina Bifida: Level ________________________ [ ] Dyscogenic Spondylosis Level _______________________________ (IXR43) (IXR44) (IXR45) (IXR46) (IXR47) (IXR48) (IXR20)

George's Line: [ ] Neutral Lateral: Level ___________________ (IXR25) [ ] Hyperflexion: Level _____________________ (IXR26) [ ] Hyperextension: Level __________________ (IXR15) Cervical Curve: [ ] Loss [ ] Exxageration [ ] Reversed Scoliosis: [ ] "S" Shaped Entire Spine [ ] "S" Shaped Ideopathic [ ] Right Rotatory: Level ________ Deg. ______ [ ] Left Rotatory: Level ________ Deg. ______ (Type) Write in any Tumors, Fractures, Etc.: _______________________________________________ _______________________________________________ _______________________________________________ (IXR50) (IXR51) (IXR52) (IXR35) (IXR36) (IXRSR) (IXRSL)

Alteration of McNab's Line: [ ] I.V.F.: Level _____________________________ (IXR32) [ ] Instability Level __________________________ (IXR33) Lumbar Gravity Line: [ ] Hyperlordosis Lumbar [ ] Hypolordosis Lumbar Spinal Instability: [ ] Lumbo-Sacral Instability: Deg. _______________ [ ] Hema Vertebra: Level _____________________ [ ] Assymetrical Facets: Level _______________________________ [ ] Facet Syndrome: Level ____________________ (IXR30) (IXR31) (IXR34) (IXR28) (IXR54) (IXR29)

Anatomical Short Leg: [ ] Right Short By: _______________________mm (IXRRS) [ ] Left Short By: ________________________mm (IXRLS) Pelvic Level Right Side: [ ] High: _______________________________mm (IXRH) [ ] Low: _______________________________mm (IXRL)

X-RAYINTERPRET ATION

Patient Name:___________________________________________________ Date:_____________________________ Acct.#:__________________ CERVICAL SPINE X-RAY INTERPRETATION: [ I (INITIAL EXAM) + X + CODE] Cervical X-Ray Discussion: _________________________________________________________________________________________________________ Cervical Curve: Ligamentous Changes: George's Line: [ ] Normal (IXC13) [ ] Anterior Longitudinal (IXP01) Level__________ [ ] Continuity Break (IXC01) Level_________ [ ] Loss (IXC14) [ ] Posterior Longitudinal (IXP02) Level_________ [ ] Motor Unit Hyperflexion (IXC02) Level_______ [ ] Straightening (IXC15) [ ] Motor Unit Hyperextension (IXC03) Level________ [ ] Exxageration (IXC16) Disc Height: [ ] Kyphosis (IXG10) [ ] Normal (IXC08) Cervical Facet: [ ] Decreased Minimal (IXC09) Level___________ [ ] Facet Sclerosis Not Present (IXC04) Transverse Processes: [ ] Decreased Moderate (IXC10) Level__________ [ ] Facet Sclerosis Minimal (IXC05) [ ] Normal (IXC17) [ ] Decreased Advance (IXC11) Level___________ [ ] Facet Sclerosis Moderate (IXC06) [ ] Elongated (IXC18) [ ] Increased (IXC12) Level___________________ [ ] Facet Sclerosis Advanced (IXC07) Cervical Ribs: [ ] None (IXC19) [ ] Unilateral Rt. (IXC20) [ ] Unilateral Lt. (IXC21) [ ] Bi-lateral (IXC22) Static Intersegmental Malpositions: (see instructions below in Lumbar Spine section) Code_________ Which Vertebra_______________ Code_________ Which Vertebra_______________ Code_________ Which Vertebra_______________ Luska Joint: [ ] Normal (IXC23) Left: Level [ ] Minimal (IXC24) ____________ [ ] Moderate (IXC25) ___________ [ ] Advanced (IXC26) ___________

Right: Level [ ] Minimal (IXC27) ____________ [ ] Moderate (IXC28) ___________ [ ] Advanced (IXC29) ___________

THORACIC SPINE X-RAY INTERPRETATION: [ I (INITIAL EXAM) + X + CODE] Thoracic X-Ray Discussion: _________________________________________________________________________________________________________ Thoracic Curve: Thoracic Disc Height: Ligamentous Changes: [ ] Normal (IXT14) [ ] Normal (IXT09) [ ] Anterior Longitudinal (IXP01) Level__________ [ ] Loss (IXT15) [ ] Decreased Minimal (IXT10) Level___________ [ ] Posterior Longitudinal (IXP02) Level_________ [ ] Exxageration (IXT16) [ ] Decreased Moderate (IXT11) Level__________ [ ] Decreased Advance (IXT12) Level___________ Pedicle: Costo-Transverse: [ ] Increased (IXT13) Level___________________ Right: [ ] Facet Sclerosis Not Present (IXT01) [ ] Overdeveloped (IXA40) Level_____________ [ ] Facet Sclerosis Minimal (IXT02) Thoracic Scoliosis: [ ] Underdeveloped (IXA41) Level____________ [ ] Facet Sclerosis Moderate (IXT03) [ ] None Present (IXT28) Left: [ ] Facet Sclerosis Advanced (IXT04) [ ] Rt. Scoliosis (IXT29) [ ] Overdeveloped (IXA42) Level_____________ [ ] Lt. Scoliosis (IXT30) [ ] Underdeveloped (IXA43) Level____________ Costo Vertebral: [ ] Rt. Rotatory (IXT31) Bi-Lateral: [ ] Facet Sclerosis Not Present (IXT05) [ ] Lt. Rotatory (IXT32) [ ] Overdeveloped (IXA44) Level_____________ [ ] Facet Sclerosis Minimal (IXT06) [ ] Underdeveloped (IXA45) Level____________ [ ] Facet Sclerosis Moderate (IXT07) Static Intersegmental Malpositions: (see instructions below in Lumbar Spine section) [ ] Facet Sclerosis Advanced (IXT08) Code_________ Which Vertebra_______________ Code_________ Which Vertebra_______________ Code_________ Which Vertebra_______________ Code_________ Which Vertebra_______________ LUMBAR SPINE X-RAY INTERPRETATION: [ I (INITIAL EXAM) + X + CODE] Lumbar X-Ray Discussion: _________________________________________________________________________________________________________ Lumbar Curve: Lumbar Disc Height: Ligamentous Changes: Lumbar Scoliosis: [ ] Normal (IXL05) [ ] Normal (IXL10) [ ] Ant. Longitudinal (IXP01) Level__________ [ ] None Present (IXG39) [ ] Loss (IXL06) [ ] Decreased Minimal (IXL01) Level___________ [ ] Post. Longitudinal (IXP02) Level_________ [ ] Rt. Scoliosis (IXG25) [ ] Straightening (IXL07) [ ] Decreased Moderate (IXL02) Level__________ [ ] Lt. Scoliosis (IXG26) [ ] Exxageration (IXL08) [ ] Decreased Advance (IXL03) Level___________ Pedicle: [ ] Rt. Rotatory (IXG22) [ ] Increased (IXL04) Level___________________ Overdeveloped: Underdeveloped: [ ] Lt. Rotatory (IXG23) Lumbar Facet Sclerosis: [ ] Right (IXA40) [ ] Right (IXA41) [ ] None (IXP05) George's Line: [ ] Left (IXA42) [ ] Left (IXA43) [ ] Minimal (IXP06) [ ] Continuity Break (IXC01) Level______________ [ ] Bi/Lat. (IXA44) [ ] Bi/Lat. (IXA45) [ ] Moderate (IXP07) [ ] Motor Unit Hyperflexion (IXC02) Level_________ Level_____________ Level____________ [ ] Advanced (IXP08) [ ] Motor Unit Hyperext. (IXC03) Level___________ Anatomically Short Leg: Lumbar Facet Facing: [ ] Right Short By: _____________mm (IXG47) Sagittal: Semisaggital: Coronal: [ ] Left Short By: ______________mm (IXG48) [ ] Rt. (IXA24) [ ] Rt. (IXA23) [ ] Rt. (IXA22) [ ] Lt. (IXA28) [ ] Lt. (IXA29) [ ] Lt. (IXA30) Static Intersegmental Malpositions: [ ] Bi/Lat (IXA34) [ ] Bi/Lat (IXA35) [ ] Bi/Lat (IXA36) Use following procedure: Begin with IX, & then select from list alphabetically until a 5-digit code is attained (example: IXA00 or IXADE). Level__________ Level__________ Level__________ Oblique: Overdeveloped: Underdeveloped: A=flexion C=lateral flexion left E=rotation left G=anterolisthesis [ ] Rt. (IXA25) [ ] Rt. (IXA26) [ ] Rt. (IXA27) B=extension D=lateral flexion right F=rotation right H=retrolisthesis I=osseous foraminal encroachment [ ] Lt. (IXA33) [ ] Lt. (IXA32) [ ] Lt. (IXA31) [ ] Bi/Lat (IXA37) [ ] Bi/Lat (IXA38) [ ] Bi/Lat (IXA39) Code________ Which Vertebra_________ Code________ Which Vertebra_________ Level__________ Level__________ Level__________ Code________ Which Vertebra_________ Code________ Which Vertebra_________

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