Chiropractic Narrative Report

CHIROPRACTIC NARRATIVE REPORT

Prepared by: [YOUR NAME]

I. Introduction

This Chiropractic Narrative Report provides a comprehensive overview of the patient's condition, treatment plan, and progress. It aims to communicate relevant findings to healthcare providers, patients, and related stakeholders effectively.

II. Patient Information

1. Personal Details

Name

Houston Smith

Age

35

Gender

Male

Address

Dallas, TX 85224

Contact Number

222 555 7777

2. Medical History

Houston has a history of chronic lower back pain and suffers from occasional neck stiffness. Past medical reports indicate episodes of migraines. No previous significant medical interventions or surgeries are noted.

III. Clinical Findings

1. Initial Assessment

  • Postural Analysis: Evidence of mild scoliosis

  • Range of Motion: Restricted lumbar flexion

  • Palpation: Tenderness in the L4-L5 region

2. Diagnostic Testing

Results from the diagnostic tests are essential to comprehensively understand the patient's condition. The following tests were conducted:

  • X-rays: Indicate degenerative disc changes at L4-L5

  • MRI: No herniations detected, slight bulging at L5-S1

IV. Treatment Plan

1. Short-term Goals

The short-term goals are formulated to address acute symptoms and enhance functionality as quickly as possible. Key objectives include:

  • Pain relief through manual adjustments

  • Improving mobility in affected areas

  • Reducing inflammation

2. Long-term Goals

Focusing on sustainable recovery, long-term goals aim to prevent recurrence and improve overall spine health. They encompass:

  • Spinal alignment maintenance

  • Developing a strengthening exercise routine

  • Educating on ergonomic practices

3. Frequency and Duration

The proposed treatment plan outlines a schedule that adapts to patient response:

  • Initial phase: Three sessions per week for four weeks

  • Follow-up phase: Weekly sessions for eight weeks

  • Maintenance phase: Bi-monthly sessions, evaluating progress regularly

V. Progress Evaluation

1. Re-assessment Findings

During follow-up appointments, the patient showed notable improvements. Key re-assessment findings include:

  • Reduced pain ratings reported by the patient

  • Increased range of motion, particularly in the lumbar region

  • Observation of improved postural alignment

2. Patient Feedback

Feedback from the patient indicates a positive response to the treatment:

  • Houston reports increased comfort during daily activities.

  • Experiences fewer occurrences of pain and stiffness.

  • Expresses confidence in maintaining lifestyle changes suggested.

VI. Conclusion

The Chiropractic Narrative Report consolidates essential patient information, clinical assessments, and treatment plans. Continuous evaluation and adaptation of the treatment plan will ensure ongoing improvement and long-term health benefits for the patient.

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