Diagnosis/Clinical Impression #1:

Cervical subluxation (739.1) Cervical sprain/strain (847.0) Cervicothoracic subluxation (839.00) Neck pain (723.1) Cervical rib (756.2) Dizziness, vertigo (780.4)

Complicated by: Loss of Cervical Lordosis.

Associated with: Decreased range of motion.

Resulting in: Headaches.

Diagnosis/Clinical Impression #2:

Low back pain (724.2) Backache (724.5) Lumbar radiculitis (724.4)

Complicated by: Arthritis.

Associated with: Muscle spasms.

Resulting in: Lumbar pain.

Recommended Spinal Manipulation Frequency: 3 times per week for 4 weeks.

Rehab: Passive & Active cervical rehab.

Structural Support: None needed at this time.

Short Term Goals: Decrease pain, inflammation, muscle tightness and increase vertebral motion and decrease swelling/edema, improve gait pattern, improve stability.

Long Term Goals: 100% recovery anticipated, but length of time unknown at this time.

Due Date: 01/01/2007

Follow Up Procedures: Reexamination, Exercises and X-ray.

Restrictions: None at this time.

Special Instructions: Spinal care class and discuss sleeping position and cervical pillow usage.

Patient Employment:

Off Work: From 11/01/2006 To: 12/01/2006

Lifestyle/Diet Modification/Nutritional Support: There were no changes recommended.

Consultation: This was scheduled with patient's other doctor for 11/5/06.

Additional Diagnostic testing: The following additional studies are recommended: Imaging: Ultrasound to lumbar spine.

Recommended by Doctor:

Full Chiro, DC