To:___________________________________                     Re:___________________________________
      ___________________________________                     Patient:________________________________
      ___________________________________                     Date of Occurrence:______________________
Att:___________________________________                      File No:________________________________
                                                                                                 Date of this Report:_______________________ 

History   __________________________________________________________________

X-Ray Examination __________________________________________________________________

Analysis  __________________________________________________________________

Corrective Care __________________________________________________________________

Currently under corrective care_________________________________________
Currently under stabilizing care to strengthen area of involvement
and soft tissue______________________________________________________
Currently under periodic care because of reoccuring symptoms associated with spine and relieved subsequent to care____________________________________
Currently under maintenance care_______________________________________

Improvement impaired due to__________________________________________
__________________________________________________________________

Spinal correction anticipated by________________________________________
Spinal correction anticipated, but length of time required is not know
at this time_________________________________________________________
Complete correction is not expected
Reason:___________________________________________________________ __________________________________________________________________

Remarks   _________________________________________________________________
 

Signed________________________________________________ 

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