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Chiropractic Check-In
Daily Progress Note
📁 Drive
Patient Check-In
Welcome!
Type your name below. If you've visited before, we'll load your last check-in automatically.
Find Your Record
Last Visit Summary
Enter Staff PIN
Incorrect PIN
⏳ Patients Awaiting Provider
How are you feeling?
Tap your answers — most patients finish in under 60 seconds.
Visit Info
Overall — Compared to Last Visit
Pain Level Right Now (0 = none · 10 = worst imaginable)
0 None10 Worst
0
Primary Region(s) — Select All That Apply
0/40
Current Symptoms — Select All That Apply
Functional Status Today
Almost done!
A few quick safety questions, then sign below.
Since Your Last Visit
0/120
⚠️ Red Flag Noted — Please Alert Staff Immediately
New neurological symptoms require urgent evaluation. Please let our front desk team know right now.
0/120
0/120
Goal for Today's Visit (optional)
Anything Else for the Doctor? (optional)
0/240
Patient Attestation & Consent
Notice of Privacy Practices: By signing below you acknowledge receipt of this practice's Notice of Privacy Practices and consent to the use and disclosure of your protected health information as described therein.
Informed Consent for Chiropractic Care: I voluntarily consent to chiropractic evaluation and treatment. I understand the nature, benefits, and risks of chiropractic care including but not limited to spinal manipulation, and that no guarantee of results has been made.
Accuracy Attestation: I attest that the information I have provided in this check-in is true, accurate, and complete to the best of my knowledge.
Timestamp: —
✍ Sign with finger or stylus
x ___________________________
✓
Thank you, there!
Your check-in is complete.
Please hand the iPad to our team — your provider will be right with you!
—
⏳ Patient signature pending — collect after treatment
⚕️ Clinician Section — Patient: —
🎙 Voice fill available — Use the mic panel (bottom-right) to dictate objective findings, diagnoses, and treatment. Say: "L4-L5 hypomobility, adjusted Diversified, applied heat and e-stim, return in one week"
Patient Self-Report
Review before beginning your objective findings.
Auto-Generated Subjective (S)
—
✓ Copied!
⚠️ Red Flag — Urgent Evaluation Required
Patient reported new or worsening neurological symptoms. Prioritize evaluation before proceeding with spinal manipulation.
⚕️ Objective Findings & Diagnosis — —
Objective Assessment
Palpation & Physical 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
M54.50Low Back Pain, Unspecified
M54.02Cervicalgia
M47.816Spondylosis, Lumbar — No Myelopathy
M79.80Nonspecific Musculoskeletal Disorder
⚕️ Treatment Performed — —
Treatment
Adjustment Technique Preference by Region
Select preferred technique for each spinal region.
Adjustment Codes
Cervical
Thoracic
Lumbar/Sacral
Modalities & Therapies
Treatment Notes & Plan
of
⚕️ Review, Sign & Export — —
Review & Finalize
Clinician Attestation & Signature
Clinician Attestation: I attest that I personally performed or directly supervised all services rendered for this patient on this date. The documentation accurately reflects the services provided and my clinical findings and judgment. All services were medically necessary.
Provider: — · Timestamp: —
✍ Provider signature
x ___________________________
✍ Patient Signature Required
Combined Patient Attestation — Post-Treatment
By signing below I confirm that:
• I received the chiropractic services documented in this visit note
• I consent to the treatment provided and have had the opportunity to ask questions
• I authorize billing of my insurance and/or accept financial responsibility for today's services
• The information I provided during check-in is accurate and complete