Colleyville Chiropractic

Daily Check-In & Progress Note

Dr. Jon Rudy Urrutia, D.C.
(817) 420-7696

Patient Check-In

Good to see you!

Type your name to pull up your last visit, or start fresh below.

Patient Lookup

Your Name

Last Visit Summary

How are you feeling?

Quick check-in — most patients finish in under 60 seconds.

Visit Info

Full Name

Date

Appointment Time

Overall — Compared to Last Visit

😊 Better 😐 Same 😟 Worse

Pain Level Today (0 = none · 10 = worst imaginable)

0
None 10
Worst

Primary Region(s) — Select All That Apply

Neck Mid-Back Low Back SI/Pelvis Hip Shoulder Elbow Wrist/Hand Knee Ankle/Foot Headache/TMJ Other Wellness / No complaints

0/40

Symptoms — Select All Applying Today

Tightness/Stiffness Ache Sharp Pain Numb/Tingle Burning Weakness Balance Issues Sleep Disturbance None of the Above

Functional Impact Today

None Mild Moderate Severe

Movement Today Feels:

Normal Slightly Limited Limited

Walking/Standing Tolerance:

Normal Reduced

Work/Daily Activities:

Normal Some Limitation Hard to Do

A few quick questions

Almost done — then just sign and hand to staff.

Since Your Last Visit

New injury or incident?

No Yes

0/120

New or worsening numbness, weakness, or bowel/bladder changes?

No Yes — possible red flag

⚠️ Red Flag Noted
Please let our front desk know immediately. You may continue submitting and a clinician will prioritize your evaluation today.

Any medication changes since last visit?

No Yes

0/120

Goals for Today's Visit

Pain Relief Mobility Performance Maintenance/Wellness Posture Sleep

Anything Else for the Doctor?

0/240

Patient Attestation & Signature

I, the undersigned patient, attest that the information provided in this check-in is accurate and complete to the best of my knowledge. I understand this information will be used as part of my chiropractic medical record. I consent to today's chiropractic evaluation and treatment as discussed with my provider.

Timestamp: —

I confirm this information is accurate and I consent to today's visit and treatment

✍ Sign with finger or stylus

x ___________________________

✓

Thank you, there!

Your check-in is complete.

Please hand the iPad to our team — Dr. Urrutia will be right with you!

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⚕️ Clinician Section — Patient: —

Patient Self-Report

Review before beginning your objective findings.

Auto-Generated Subjective (S) — SOAP

—

⚕️ Objective Findings & Diagnosis — —

Assessment

Palpation Findings

Findings Present:

Edema Hypertonicity Muscle Spasm Tenderness ROM Restriction Anatomical Anomaly

Leg Length:

Even Short Left Short Right Anatomical Diff.

Corrected After TX Not Corrected Anatomical — No Correction Expected

Clinician Notes on Objective Findings:

Diagnosis (ICD-10)

M99.01Cervical Segmental Dysfunction

M99.02Thoracic Segmental Dysfunction

M99.03Lumbar Segmental Dysfunction

M99.04Sacral Segmental Dysfunction

M79.18Myalgia, Other Site

M54.30Sciatica, Unspecified Side

M54.50Low Back Pain, Unspecified

M54.02Cervicalgia

M47.816Spondylosis, Lumbar w/o Myelopathy

⚕️ Treatment Performed — —

Treatment

Adjustment Technique Preferences by Region

Select the preferred technique for each region. "Do Not Adjust" overrides all others.

Adjustment Codes & Spinal Levels

S00.01 Wellness 98940 (1–2 regions) 98941 (3–4 regions) 98942 (5 regions) 98943 (Extremity)

Spinal Levels Adjusted:

Cervical

Thoracic

Lumbar/Sacral

Modalities & Therapies

Treatment Notes & Plan

Treatment Notes (open text)

Visit # / Total

Frequency

Return

Home Care Instructions

Yes No

Home Care Details (if applicable)

Care Response

Excellent Good Fair Poor

Progress

Improving No Change Set-Back New Complaint

Doctor's Notes

⚕️ Review, Sign & Export — —

Review & Finalize

Clinician Attestation & Signature

I attest that I personally performed or directly supervised the services rendered for this patient on this date, that the information documented is accurate and based on my own observation and clinical judgment, and that the services were medically necessary. This note complies with applicable documentation requirements.

Signed: Dr. Jon Rudy Urrutia, D.C. — Timestamp: —

I attest to the accuracy of this clinical note and authorize my electronic signature below

✍ Doctor signature

x ___________________________

Date Signed

Save to Google Drive (Optional)

Enter a Google Drive folder link and the PDF filename will be auto-named as FirstInitial.LastName MM-DD-YY.pdf (e.g. J.Urrutia 02-22-25.pdf). Click the Drive button below to open your folder.

Patient Last Name (for filename)

Then use Print → Save as PDF with the filename shown below

🔒

Ready for Next Patient

The previous note has been saved.
Hand the iPad to the next patient.

All patient records remain saved. Each patient's data is private.