Good to see you!

Are you a returning patient? Type your name to pull up your previous visit, or continue as a new patient.

Patient Lookup

Your Name

Welcome back, there!

Here's what we have from your last visit. Tell us what's the same and what's changed.

Last Visit Summary

Is this a Wellness Visit today?

✓ Yes — Wellness Only No — I have complaints

Your Complaints — Same or Different?

Any New Conditions or Additional Notes?

New Condition / Injury Nothing New

Additional Comments

Today's Appointment Time

Patient Signature

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x ___________________________

Welcome!

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Patient Information

Full Name

Today's Date

Appointment Time

Is this a Wellness Visit?

✓ Yes — Wellness Only I have concerns

Your Symptoms Today

Select your pain region and rate each complaint one at a time.

Additional Notes

Any last notes for your doctor, then please sign below.

Notes & New Conditions

Any new condition or injury since your last visit?

Yes No

Additional Comments

Patient Signature

By signing, you confirm the information provided is accurate. Please use your finger or stylus to sign in the green-outlined box below.

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x ___________________________

Patient's Self-Report

Review what the patient submitted before beginning your assessment.

Assessment & Palpation

Palpation Findings

Findings Present:

Edema Hypertonicity Muscle Spasm Tenderness

Muscle Tenderness — Select Left, Right, or Both:

Leg Length Discrepancy

Finding:

Short Left Leg Short Right Leg Even Anatomical Difference

After Treatment:

Corrected After TX Not Corrected Anatomical — No Change Expected

Treatment Performed

Adjustment Codes

Spinal Levels Adjusted:

Cervical

Thoracic

Lumbar / Sacral

Modalities & Therapies

Doctor's Notes & Plan

Visit # / Total

of

Return

Doctor's Notes

Review & Sign

Treating Doctor Signature

Dr. Jon Rudy Urrutia, D.C. — Please sign to complete this progress note.

✍ Doctor signature — sign with finger or stylus

x ___________________________

Date Signed

✓ Note Complete

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Cervical

Thoracic

Lumbar / Sacral

Big Ideas,
Real Impact.

Elevate Your Health.

Cervical

Thoracic

Lumbar / Sacral

Big Ideas, Real Impact.

Elevate Your Health.

Big Ideas,
Real Impact.