Loading...
HomeMy WebLinkAbout14-5082 Supreme Court'of.Pennsylvania Court of Common Pleas - - • - . For Prothonotary Use Only: Civil ,Cover=S eet r ,A� ' LI� Docket No: V'MB' County /y-sob The l/lfvinLation c'ollectc>d on thisfor"nl is used solely for court adi/Li/Listratlon proposes. TlLis form does /,ot supplerllelLt of replace the filing Cu1Cl Sel"Wc'e of pleadlfl�s or otllC P pClpel"S CLS I'L>q'1LL1'ed l7l'lati'I%OI'7'lllc'5 Of C011l't. nTramnsfernfrom t of Action: S Writ of Summons Another Jurisdiction Petition E ❑ Declaration of Taking C Lead Plaintiffs Name: TErte rr y �� ), y� Lead Def ndant's Name: Ioney damages requested?�YeS ❑ No Dollar Amount Requested: ❑within arbitration limits (check one) tside arbitration limits Na Class Action Suit? ❑Yes No Is this an MDJAppeal? ❑ Yes "'No Ame of Plaintiff/Appellant's Attorney: T"�y�� , Ogg ❑ :ltecf4: l,er"ee 310 z ttol"tse� (are a Sellf-Represented [Pro Sej Litigant) Nature of the Case: Place an "X"to the left of the ONE case category that most accurately describes your PRIMARY CASE. If you are making more than one type of claim, check the one that You consider most important. TORT(do not include Mass Tort) CONTRACT(do not include Judgments) CIVIL APPEALS ❑ Intentional ❑ Buyer Plaintiff ❑ Malicious Prosecution Administrative Agencies otor Vehicle ❑ Debt Collection:Credit Card [] Board of Assessment ZI Nuisance ❑ Debt Collection:Qther ❑ Board of Elections S ❑ Premises Liability ❑ Dept.of Transportation ❑ Product Liability(does not include ❑ Statutory Appeal:Other E »lass tort) ❑ Employment Dispute: ❑ Slander/Libel/Defamation Discrimination C ❑ Other: ❑ Employment Dispute:Other ,r Zoning Board ❑ Other: I O 71MASSTORTOther: Nrt-DES ❑ Toxic Tort-Implant Toxic Waste REAL PROPERTY 1VIISCELLANEOUS B ❑ Other: ❑Ejectment ❑ Common Law/Statutory Arbitration ❑Eminent Domain/Condemnation ❑Declaratory Judgment ❑ Ground Rent ❑ Mandamus ❑ Landlord/Tenant Dispute ❑ Non-Domestic Relations PROFESSIONAL LIABLITY ❑ Mortgage Foreclosure:Residential Restraining Order ❑ Dental ❑ Mortgage Foreclosure:Commercial ❑Quo Warranto ❑ Partition ❑ Legal ❑Replevin ❑ Quiet Title ❑ Medical ❑Other: ❑ Other Professional: ❑ Other: Updated 111P_Oil IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,PENNSYLVANIA CIVIL DIVISION Plaintiff(s)&Address(es) Chad Glazer& Leslie Loper-Glazer, Co-Plaintiffs 320 Shady Lane Apt 4 Enola, PA 17025-2258 VS. Case No. Civil Term Defendant(s)&Address(es) Civil Action Charles R Uhrich 113 Hollow View Ln Enola, PA 17025-1949 C) Cn.� PRAECIPE FOR WRIT OF SUMMONS r— x CD TO THE PROTHONOTARY/CLERK OF SAID COURT: ' � 1 tri Issue summons in the above case Writ of Summons shall be issued and forwarded to Attorne her—C4.. 1 Ci e c is Date: 29 Aug 2014 Signature of Attorney Print Name: Paul Bradford Orr Address: 50 East High Street Carlisle, PA 17013 Telephone#:(717)258-8558 Supreme Court ID Number: 71786 WRIT OF SUMMONS .TO: ARLV RR 4 YOU ARE NOTIFIED THAT THE ABOVE-NAMED PLAINTIFFS)HAS/HAVE CONAMNCED AN ACTION AGAINST YOU. Prothonotary/ Jerk,Civil Division Date:�( Deputy C' C.)G 2 FAFILES1Cl1ents0050 Donegall3050 Currer4\3050.722 U050.722.pra I.wpd Revised: 9/8/14 1:06PM Daniel K. Deardorff, Esquire MARTSON DEARDORFF WILLIAMS OTTO GILROY & FALLER MARTSON LAW OFFICES I.D. 17837 10 East High Street Carlisle, PA 17013 (717) 243-3341 Attorneys for Defendant ‘.. THE PROTH0}03-1,-, 21114 SEP -8 PM 2: 1 7 CUMBERLAND COUNTY PENNSYLVANIA CHAD GLAZER & LESLIE LOPER-GLAZER, Plaintiffs V. : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : NO. 14-5082 : CIVIL ACTION - LAW CHARLES R. UHRICH, Defendant : JURY TRIAL DEMANDED PRAECIPE TO THE PROTHONOTARY OF CUMBERLAND COUNTY: Enter the appearance of MARTSON LAW OFFICES on behalf of Defendant in the above matter and issue a rule upon the Plaintiff to file a Complaint within twenty (20) days from service thereof or suffer judgment of non pros. Defendant hereby demands a twelve juror jury trial in the above captioned action. Dated: ott*Li MARTSON LAW OFFICES By Daniel K. Deardorff, Esquire I.D. No. 17837 10 East High Street Carlisle, PA 17013 (717) 243-3341 Attorneys for Defendant RULE AND NOW, this 4Lday of , 20/ , a Rule is issued upon the Plaintiff to file a Complaint within twenty (20) days from service hereof -PaggE Prothonotary CERTIFICATE OF SERVICE I, Ami J. Thumma, an authorized agent for Martson Law Offices, hereby certify that a copy of the foregoing Praecipe was served this date by depositing same in the Post Office at Carlisle, PA, first class mail, postage prepaid, addressed as follows: Paul B. Orr, Esquire 50 East High Street Carlisle, PA 17013 MARTS ON LAW OFFICES By Dated: GINN Ai J. Thjnma Ten East High Street Carlisle, PA 17013 (717) 243-3341 SHERIFF'S OFFICE OF CUMBERLAND COUNTY Ronny R Anderson Hi Hi- OF F Sheriff GF THE PROTHONOTAi''," 15W Jody S Smith Chief Deputy 201.1i SEP 12 PH 3: 148 Richard W Stewart Solicitor ovne QFT4F., $MERIFF CUMBERLAND COUNTY PENNSYLVANIA Chad Glazer (et al.) vs. Charles R Uhrich Case Number 2014-5082 SHERIFF'S RETURN OF SERVICE 09/04/2014 05:07 PM - Deputy Christopher Sharpe, being duly sworn according to law, served the requested Writ of Summons by "personally" handing a true copy to a person representing themselves to be the Defendant, to wit: Charles R Uhrich at 113 Hollow View Lane, East Pennsboro, Enola, PA 17025. CHRISTO R SHARPE, DEPUTY SHERIFF COST: $45.44 SO ANSWERS, September 08, 2014 (c) CountySuite Shoriff, Teleosart, Inc. RONNIY R ANDERSON, SHERIFF CHAD GLAZER & LESLIE LOPER- GLAZER, Plaintiffs v. CHARLES R. UHRICH, Defendant : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, : PENNSYLVANIA : NO. 14-5082 : CIVIL ACTION - LAW : JURY TRIAL DEMANDED ACCEPTANCE OF SERVICE I hereby accept service of the Complaint on behalf of the Defendant, Charles R. Uhrich in the above -captioned action and I certify that I am authorized to do so. DATE: H(3 By: Daniel C Deardorff, Esq. Attorney for Defendant -I CHAD GLAZER & LESLIE LOPER- : IN THE COURT OF COMMON PLEAS GLAZER, : CUMBERLAND COUNTY, Plaintiffs : PENNSYLVANIA v. : NO. 14-5082 CHARLES R. UHRICH, : CIVIL ACTION - LAW Defendant : JURY TRIAL DEMANDED CERTIFICATE OF SERVICE AND NOW, this 3rd day of November, 2014, Paul Orr, Esquire, Attorney, in the above - captioned action, served a true copy of the Complaint, in the above -captioned matter, upon Daniel K. Deardorff, Esquire by hand delivery on November 3, 2014, in his Law Offices located at 10 East High Street, Carlisle, PA 17013 at J 130 A.M. Dated: i4 By: aul Bradf• d Orr, Esquire Law Offices of Paul Bradford Orr 50 East High Street Carlisle, Pennsylvania 17013 Telephone Number: (717) 258-8558 Fax Number: (717) 258-5289 Attorney for Plaintiffs CHAD GLAZER & LESLIE LOPER- GLAZER, Plaintiffs v. Os. SNE PRO -MOH, Cl1MgERLSYSL�RNi A COUNTY PENN : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, : PENNSYLVANIA : NO. 14-5082 CHARLES R. UHRICH, : CIVIL ACTION - LAW Defendant : JURY TRIAL DEMANDED NOTICE YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this Complaint and Notice are served, by entering a written appearance personally or by attorney and filing in writing with the Court your defenses or objections to the claims set forth against you. You are warned that, if you fail to do so, the case may proceed without you and a judgment may be entered against you by the Court without further notice for any money entered against you by the Court without further notice for any money claimed in the Complaint or for any other claim or relief requested by the Plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCE FEE OR NO FEE. CUMBERLAND COUNTY BAR ASSOCIATION 2 LIBERTY AVENUE CARLISLE, PA. 17013 (717) 249-3166 Law Offices of Paul Bradford Orr 50 East High Street Carlisle, Pennsylvania 17013 Telephone Number: (717) 258-8558 Fax Number: (717) 258-5289 Attorney for Plaintiffs CHAD GLAZER & LESLIE LOPER- : IN THE COURT OF COMMON PLEAS GLAZER, : CUMBERLAND COUNTY, Plaintiffs : PENNSYLVANIA v. : NO. 14-5082 CHARLES R. UHRICH, : CIVIL ACTION - LAW Defendant : JURY TRIAL DEMANDED NOTICIA LE HAN DEMANDADO A USTED EN LA CORTE. Si usted quiere defenderse de estas demandas expuestas en las paginas siguientes, usted tiene veinte (20) dias de plazo al partir de Ia fecha de Ia demanda y la notificacion. Usted debe presentar una apariencia escrita o en persona o por abogado y archivar en la corte en forma escrita sus defensas o sus objeciones a las demandas en contra de su persona. Sea avisado que si usted no se defiende, la carte tomaro medidas y puede entrar una orden contra usted sin previo aviso o notoficacaion y por cualquier queja o alivio que es pedido en la peticion do demanda. usted puede perder dinero o sus propiededas o otros derechos importantes para usted. LLEVE ESTA DEMANDA A UN ABOGADO IMMEDIATAMENTE. SI NO TIENE ABOGADO 0 SI NO TIENE EL DINERO SUFICIENTE DE PAGAR TAL SERVICIO, VAYA EN PERSONA 0 LLAME POR TELEFONO A LA OFICINA CUYA DIRECCION SE ENCUENTRA ESCRITA ABAJO PARA AVERIGUAR DONDE SE PUEDE CONSEGUIR ASISTENCIA LEGAL. SI USTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES POSIBLE QUE ESTA OFICINA LE PUEDA PROVEER INFORMACION SOBRE LAS AGENCIAS QUE OFREZCAN SERVICIOS LEGALES SIN CORGO 0 BAJO COSTO A PERSONAS QUE CUALIFICAN. Lawyer Referral and Information Service CUMBERLAND COUNTY BAR ASSOCIATION 2 LIBERTY AVENUE CARLISLE, PA. 17013 (717) 249-3166 Law Offices of Paul Bradford Orr 50 East High Street Carlisle, Pennsylvania 17013 Telephone Number: (717) 258-8558 Fax Number: (717) 258-5289 Attorney for Plaintiffs • CHAD GLAZER & LESLIE LOPER- : IN THE COURT OF COMMON PLEAS GLAZER, : CUMBERLAND COUNTY, Plaintiffs : PENNSYLVANIA v. : NO. 14-5082 CHARLES R. UHRICH, : CIVIL ACTION - LAW Defendant : JURY TRIAL DEMANDED COMPLAINT AND NOW, come the Plaintiffs, Chad Glazer and Leslie Loper -Glazer, by and through their attorney, Paul Bradford Orr, and respectfully represent the following: FACTS APPLICABLE TO ALL COUNTS 1. Plaintiff, Chad Glazer, is an adult individual who currently resides at 320 Shady Lane, Apt. 4, Enola, Cumberland County, Pennsylvania 17025-2258. 2. Plaintiff, Leslie Loper -Glazer, is an adult individual who currently resides at 320 Shady Lane, Apt. 4., Enola, Cumberland County, Pennsylvania 17025-2258. 3. Plaintiffs, Chad Glazer and Leslie Loper -Glazer, are husband and wife. 4. Defendant, Charles R. Uhrich, is an adult individual whose last known address is 113 Hollow View Lane, Enola, Cumberland County, Pennsylvania 17025-1949. 5. The facts and circumstances hereinafter set forth took place on September 2, 2012, at or about 4:30 p.m. on East Penn Drive, Camp Hill, Pennsylvania. 6. At the aforesaid time and place, Plaintiff, Chad Glazer, was the operator of a 2006 Saturn Ion. 7. At the aforesaid time and place, Defendant, was the operator of a 2011 Chevrolet Malibu. 8. At the aforesaid time and place, Plaintiff, Chad Glazer, was operating the vehicle traveling in his proper lane of travel, signaling to make a left hand turn driving aforesaid Saturn Ion in Camp Hill, Cumberland County, Pennsylvania. 9. At the aforesaid time and place, Defendant, Charles R. Uhrich, was operating the Chevrolet Malibu, traveling in the same lane of travel as Plaintiff and failed to stop his vehicle upon approaching the intersection where Plaintiffs vehicle was stopped and waiting to make a left hand turn and as a result rear-ended Plaintiff. 10. The aforesaid collision was the direct and proximate result of the negligence of the Defendant Charles R. Uhrich, in operating the Chevrolet Malibu in a careless and negligent manner as follows: a. Failing to stop his vehicle before entering the intersection when facing a steady red traffic control signal in violation of § 3112(a)(3)(i) of the PA. Motor Vehicle Code; b. Driving his motor vehicle in careless disregard for the safety of persons or property in violation of § 3714 of the PA. Motor Vehicle Code; c. In failing to apply the brakes in time to avoid the collision; d. In failing to observe Plaintiffs vehicle on the highway; e. In permitting or allowing the vehicle to strike and collide with the rear of the vehicle operated by the Plaintiff. COUNT 1 CHAD GLAZER v. CHARLES R. UHRICH 11. Paragraphs 1 through 10 of Plaintiffs Complaint are incorporated herein by reference and made a part hereof as if set forth in full. 12. As a result of the aforesaid collision, Plaintiff, Chad Glazer, has suffered injuries, including but not limited to the following: (A copy of Plaintiffs medical records are attached hereto as Exhibit "A") a. On-going, intermittent acute neck pain and stiffness; b. Acute upper back pain and mid back pain. 13. As a direct and proximate result of the aforesaid injuries, Plaintiff, Chad Glazer, has undergone and in the future will undergo pain and suffering for which damages are claimed. 14. Plaintiff, Chad Glazer, was the named insured on a policy of insurance issued to him by Erie Insurance bearing policy number Q10 0704846 H which was in effect on the date of the above referenced collision. Plaintiff selected the full tort option regarding that policy. A copy of the declaration page of the said policy is attached hereto and incorporated by reference herein as Exhibit "B". Therefore, Plaintiff, Chad Glazer remains eligible to claim compensation for non -economic loss and economic loss sustained in this collision pursuant to applicable tort law. WHEREFORE, Plaintiff, Chad Glazer demands judgment against Defendant, Charles R. Uhrich for compensatory damages in an amount in excess of the amount requiring compulsory arbitration. COUNT 2 LESLIE LOPER-GLAZER v. CHARLES R. UHRICH 15. Paragraphs 11 through 14 of Plaintiffs Complaint are incorporated herein by reference and made a part hereof as if set forth in full. 16. As a result of the aforesaid collision, Plaintiff, Leslie Loper -Glazer, has suffered injuries, including but not limited to the following: (A copy of Plaintiffs medical records are attached hereto as Exhibit "C") a. Permanent nerve damage whereby Plaintiff, Leslie Loper -Glazer asserts that her treating physician informed her that she will be "on Vicodin for life". His prognosis is also forthcoming as she continues with treatment as of this date; b. Has suffered severe migraine headaches a direct and proximate cause; c. Ongoing muscle spasms; d. Ongoing neck pain, upper back, middle back and lower back pain; e. As the muscle spasms failed to subside, on or about February 18, 2014, Plaintiff, Leslie Loper -Glazer had Botox Neurological Surgery for her muscle spasms in neck and shoulder area and also to treat the ongoing migraine headaches. f. Numbness in her left arm; g. Bi -lateral upper extremity and hand numbness; h. Limited range of neck motion. 17. As a direct and proximate result of the aforesaid injuries, Plaintiff, Leslie Loper - Glazer, has undergone and in the future will undergo great pain and suffering for which damages are claimed. 18. As a further result of the aforesaid injuries, Plaintiff, Leslie Loper -Glazer, has suffered and may continue to suffer a loss of earnings for which damages are claimed. 19. As a further result of the aforesaid injuries, Plaintiff, Leslie Loper -Glazer, has and/or may in the future incur a loss of earning capacity for which damages are claimed. 20. As a further result of the aforesaid injuries, Plaintiff, Leslie Loper -Glazer, has incurred or may hereinafter incur financial expenses and losses which exceed sums recoverable under the limitations and exclusions of the Pennsylvania Motor Vehicle Financial Responsibility Law for which damages are claimed. 21. Plaintiff, Leslie Loper -Glazer, was the named insured on a policy of insurance issued to him by Erie Insurance bearing policy number Q10 0704846 H which was in effect on the date of the above referenced collision. Plaintiff selected the full tort option regarding that policy. A copy of the declaration page of the said policy is attached hereto and incorporated by reference herein as Exhibit "A". Therefore, Plaintiff, Leslie Loper -Glazer remains eligible to claim compensation for non -economic loss and economic loss sustained in this collision pursuant to applicable tort law. WHEREFORE, Plaintiff, Leslie Loper Glazer demands judgment against Defendant, Charles R. Uhrich for compensatory damages in an amount in excess of the amount requiring compulsory arbitration. Respe su • ted, LAW PA Attorn - 'or P ntiff By: Date: 1113fri Paul Bradford Orr, Esq. Attorney I.D. #71786 50 East High Street Carlisle, PA 17013 (717) 258-8558 (717) 258-5289 (fax) CHAD GLAZER & LESLIE LOPER- GLAZER, : IN THE COURT OF COMMON PLEAS Plaintiffs : CUMBERLAND COUNTY, : PENNSYLVANIA v. : NO. 14-5082 CHARLES R. UHRICH, Defendant : CIVIL ACTION - LAW : JURY TRIAL DEMANDED ATTORNEY VERIFICATION The undersigned, Paul Bradford Orr, Esquire, hereby verifies and states that: (a) He is the attorney for the Plaintiffs; (b) He is authorized to make this verification on their behalf; (c) The facts set forth in the foregoing Complaint are known to him and on October 30, 2014, he did orally, via telephone conference review the facts set forth in the foregoing Complaint with Plaintiffs; (d) The facts set forth in the foregoing Complaint are true and correct to the best of his knowledge, information and belief; and (e) He is aware that false statements herein are made subject to the penalties of 18 Pa. C.S. 4904, relating to unsworn falsification to authorities. ul Bradford Orr, Esquire 50 East High Street Carlisle, PA 17013 (717) 258-8558 Attorney for Plaintiffs Superior Court ID# 71786 MEDICAL RECORDS CHAD GLAZER PLAINTIFF'S EXHIBIT "A" DR Bush • Case No. • • Address ; Refarrod VVJI1rvi Ei,sh, P.9. Fax:717-561-8388 Oct 28 201d 02:11pm P008/008 • ` Patiant'e'Nanne IneuranCS pee. Occupatiem •: • Ago, Sex ' .• • S' M. W •C . •Ma: .Doi • Yr_ • •Cf•I.IE.F .COMPLAINT• • AO.01T.IONAL•HISTORY; PHYSICAL FINDINGS, MEDICATIONS, ,s 9 • Ji �Qi; CVIJ-vI-Vt II;I. DR Bush 1 tie nem -1(:K t-eruuer I r FIo7Z4VV)8388 THE HETRICK CENTER You hove a choice for Physical 114rapy...c hoose us! 500 Nonh Union Street 1300 Ban Crock Boulevard Midraele%an, PA 17037 Me<hnnicab,rg. PA 17050 0111cec (717) 244-2223 OSMcc: (717)796-222i Fax (717) 9444432 Fax: (7)7) 796-2229 September 7, 2012 Harrisburg RE: DOB: PI Chad Glazer 06/19/1972 CLINICAL HISTORY 20 Nath Barbara Strom Mourn Jay. PA 175$2 of'rco: (717) 492-0303 Fax (717) 492-0309 Oc(I 8�o1Fd400A 03OO r 4O 845 Sir 'Nemo Coon, Suite 11A Harrisburg, PA 17109 OBiicc: (717) G52-4002 Fax (717) 6524005 Mr. Glazer presents to The Hetrick Center of Harrisburg with chief complaints of neck pain and upper back pain, predominantly on the left side but he also not mid back pain, He had immediate pain following a motor vehicle accident which occurred on 09/02/2017. He has a long history of lower back pain since approximately 1994. He notes having just some mild to moderate irritation of the lower back prior to this motor vehicle accident. He is now in acute neck pain and upper back pain, He was a restrained driver who was rear ended on 09/02/2012 while stopped at a red light. He notes that thc car behind him may have been traveling 10t+ miles per hour. He notes having immediate pain following the collision. Hc notes having no neck pain or upper back pain previous to this motor vehicle accident. Ho notes having severe restricted range of motion and tightness with spasming in the neck and upper back. Onset was sudden. He notes that the pain quality today is a very intense stiffness and, as he describes it, a muscle jumping while trying to rotate his head in either direction, or extend or flex. Otherwise, he notes a rather intense dull achy sensation as rest. Pain severity is between a 5 and an 8/10 today on the Verbal Borg Scale. He denies any upper extremity pain or parathesia. The pain is constant and it has been constant since the date of the MVA. Symptoms am exacerbated with work. He is a tattoo artist and does prominently sit with lots of head rotation and upper extremity movement, He notes having moderate to severe difficulty performing his normal work activity, as well as many ADL activities involving prolonged head flexion, sleeping or washing/brushing teeth. Sitting increases his pain at approximately 2-3 minutes and he has rattler intense pain with rotation of the neck in either direction. He has been taking some medication which gives him some relief. He has also been using heat patches over the area which have given him no help. He does note having a headache today and daily, particularly in the AM, following the accident. He had a lumbar epidural shot in July of 2012 at a pain management clinic in Mechanicsburg. The patient was unable to recall the exact name of the facility. He notes having relatively lime pain in the low back following this shot, up until the motor vehicle accident. Please sec his intake for further details surrounding his health history. ' PHYSICAL EXAMINATION Chad is a 40 year old male, Caucasian, standing 6' 3" weighing 193 pounds. He has normal blood pressure today tested at 118/68 seated on the left side. He is pleasant and well oriented, in a moderate to severe amount of upper back and neck pain, and mild to moderate lower back pain. Postural examination reveals a right handed individual with a depressed right shoulder, left DR Bush I. FaL 7f7 -;,6l-8388 THE HETRICK CENTER Oct 28 2014 aao0pmr Pa/5/008 4 Chad Glazer Page 2 of 3 September 7, 2012 rotated head and neck, and a rather pronounced anterior head carriage at approximately 7 degrees. Hc has hyperkyphosis with a general flexion of the upper torso, Cervical range of motion is restricted and caused general pain and a `muscle jumping" activity with flexion at 20 degrees with a very jerky type, non fluid motion. Extension at 10 degrees. Bilateral lateral flexion at 20 degrees. Right rotation at 50 degrees with muscle jerking and left rotation at 70 degrees. Lumbar ranges of motion were restricted with flexion at 40 degrees, extension at 20 degrees and bilateral lateral flexion at 10 degrees with pain noted over the midline between the L3-L5 level. Orthopedic testing was positive for pain reduction with maximum cervical compression in the cervical spine, pain noted between the occipital and Cl along the midlinc. Soto -Hall test was also positive for pair reproduction noted as moderate generally in the neck towards the mid to lower portion. The patient denies any increased pain with Valsalva maneuver in the cervical spine but does have some increased pain in the lower lumbar spine. Orthopedic testing was positive for straight leg raise bilaterally in the low back at 60 degrees causing what he describes as mild pain in the midlinc between L4/L5 as indicated by the patient pointing to this area, Myotomes in the upper extremity were strong and brisk bilaterally with a 5/5 at the deltoid, bicep, wrist flexion/extension, finger abduction. Deep tendon reflexes were also normal in the upper and lower camremitics with a 2/5 at the bleep, brachioradialis, Tricep, patellar and Achilles. Myotomes were also normal in the lower extremity, He did have some increased pain with resistance to bilateral leg extension in the lower lumbar spine but it was strong bilaterally at 5/5. Chiropractic palpatory findings reveal spinal fixation / vertebral subluxation complex as noted in the SOAP note. He has relatively high muscle tonicity over the suboccipital muscles bilaterally with a 4-3, trapezius muscle with a +2-3 bilaterally with multiple trigger point, and in the paraspinals of the C-spine bilaterally elevated with a +2. He also has elevated muscle tone in the sternocleidomastoid on the right side with a +2, tenderness on palpation over the muscle with a +2 as well, TREATMENT PLAN The patient was treated today with electrical muscle stimulation, heat, light flexion distraction, manual traction to the C-spine and the appropriate specific adjustments to fixation levels. The patient was able to tolerate the care well today. l did advise him to ice the areas post treatment five minutes at each application up to five times, increase bis watcr intake and continue medication as prescribed by his PCP. Re will continue to try and avoid aggravating activities such as work and the ADL activities as noted over the next week. Goals of treatment arc to reduce pain, restore normal ranges of motion, reduce muscle tone and restore patient to pre- accident ADL. and work function. Prognosis is good in the C-spine / upper back arra, in the lumbar spine fair given the presence of pre-existing disc issues and previous episodes / flare-ups of myospasm, and the inability to remove some aggravating factor at work as well. Diagnosis is clearly stated in the SOAP note. The patient will be seen over the next two weeks, three times a week followed by are -evaluation to determine current status and need for future care. DIA GNOSTIC_ STUDIES A plain film radiographic study was secured of the cervical spine today consisting of a neutral lateral and A -P open mouth, and an A -P thoracic cervical view. The cervical neutral lateral reveals seven contiguous normally -shaped cervical vertebrae. There is a rather pronounced amount of forward head carriage measuring at approximately 7 degrees DR Bush t,, tV,. VI IU.h *+cl ltVI u ?uu6J-83A8 THE HETRICK CENTER 0i t p.3) VOa.,00l0prm, 't/'*/008 Chad Glazer Page 3 of 3 September 7, 2012 forward. Disc spacc appeared to be well prosorvcd throughout. No indication of fracture, dislocation or gross pathology seen in this view. The A -P open mouth also reveals thc occiputalf 2 complex, the dens is centrally located and intact. There arc adequate joint spaces bctwccn occiput bilaterally in the Cl lateral masses as well IS the CI lateral masses and the body of C2. The A -P upper thoracic cervical view revealed clear long apexes bilaterally as limited by Ellis vicw. There is a scoliosis which appears to be in the thoracic upper portion with a right convexity. This distorts his posture mildly with a left lateral flexed head. Uncinatc processes arc unrctnarkablo bilaxerally. Joint spaces appear well preserved. No indication of fractures, dislocation or other gross pathology seen in this view. RADIOGRAPHIC IMPRESSIO Is that of one a 7 degree forward head carriage, scoliosis in the upper thoracic as noted. Patient will follow up in approximately two days for additional treatment. Hc will i� and increase his water intake and follow the instructions as noted. It is my prefcssional opinion, with a reasonable degree of chiropractic certainty, that the subjective complaints put forth by the patient, my examination findings and evidence of ADL difficulty on his OAT forms, do directly corrclatc with thc motor vehicle accident which =tined on 09/02/12 and it is thereby medically necessary and appropriate. Ed L. Hevner, D.C. EL t 41)). PiNNACLEHEALTH Irnaging DR Bush Fax:717-561-8388 • Ed TRISTAiN High Field MRI • Open MRI • PET Imaging • Computed Tomography (CT) Bone Densitometry • X Ray / Fluoroscopy • Minimally Invasive AGE/SEX 40/ Male PATIENT NAME GLAZER, CHAD (DOB 06/19/1972) GATE OF SERYL 0111112013 Patient ID: 000196646622 Accession #: 770231421 Order #: 7283061 - MR LUMBAR W/O CONTRAST CODE: 72148 EXAM: MRI L SPINE Clinical data: Low back pain with pain and numbness down both legs. U' 41 COMPARISON: None. Oct 28 2014 02:10pm P002/008 240 Grandview Avenue Camp Hill, PA 17011 P: (717) 214-3330 F: (717) 214-3350 • Digital Mammography • Ultrasound Biopsy • Nuclear Medicine Account # 130232287 FINDINGS: There is a focus of T1 and T2 hyperintense signal in the L3 vertebral body to the right of midline consistent with a hemangioma, No other abnormal marrow signal is seen. The alignment of the lumbar spine is normal. The conus medullaris appears normal and ends at T12-L1. T12-L1: Negative. L1-L2, There are congenitally shortened pedicles resulting in mild central spinal stenosis. No disc pathology is seen, No significant neural foraminal stenosis is seen. L2-L3: There is mild diffuse disc bulge and buckling of the ligamentum flavum. These changes coupled with congenitally shortened pedicles results in mild to moderate central spinal stenosis. No neural foraminal stenosis is seen. L3-L4: There is mild diffuse disc bulge. There is T2 hyperintense signal in the posterior central disc consistent with an annular tear. No focal disc protrusion or extrusion is seen. These findings coupled with coagerritdlly "- shortened pedicles results in mild central spinal stenosis. There is mild encroachment of the basal aspect of both neural foramen.--,—�—� L4-L5: There is a small broad-based central disc protrusion with a underlying annular tear. )here is mild diffuse disc bulge and buckling of the ligamentum flavum. These changes r .Id central I stenosis, mild left and mild to moderate right neural foraminal stenosis. L5-S1: There is mild diffuse disc bulge. There is a small left paracentral disc protrusion which extends slightly below the disc level. No contact with the Si nerve roots are seen. No central spinal or neural foraminal stenosis is seen. IMPRESSION: Multilevel degenerative changes and disc protrusions as described in the body of the report. AT THE REQUEST OF WILLIAM BUSH, MD 5100 LANCASTER ST HARRISBURG PA 17111 Proud to be accredited by the American College of Radiology in Cr, MR, US, Mammography, Stereotactic and Ultrasound -Guided. Breast Biopsy, Breast MR, and by The Intersocietal Commission for Accreditation in MM, PET and Echocardiography. Our other offices: Harrisburg Hershey Linglestown Road Pane• 2I DR Bush PINNACLEHEALTH imaging Erd TRISTAN RADICLCGf Sasr.0 AL 5':S Congenitally shortened pedicles. Fax:717-561-8388 Oct 28 201i1 02:10pm P003/008 GLAZER, CHAD DOB 06/19/1972 Account # 130232287 01/11/2013 Image Review and Interpretation by: DAVID B. WAGAR MD ELECTRONICALLY SIGNED DBW / DBW PROF!' 3/n Pg 2 of 2 cc: ...'_ �•1!:• ,..• ,�,',, .- - ((//y1�/;++•• Otttt /////����.. .:. ��••��,,)) 'P�,���,.'\�•�.��j'��\� ,•�. � ¢Y V :. ' . . ‘,/ .o. . . •• .:: . .. , . • . . .. • • — .....* ..„ . ....•6.-* ;•..- '*• : . .• • s . ' 1 11 . . . . 7 . . . • DR Bush om"ug LabCorp RaritatA - IA*0f61D-y00roo„eoo ol AThOe;o1 la 69 First Avenue, Raritan, NJ 08869.1800 Fax:717-561-8388 SPECIMEN 294-425-4383-0 TYPE PRIMARY LAB S I RN . REPORT STATUS COMPLETE ADDITIONAL. LN FORVL4TION FASTING: N PHONE: 717-635-9899 DOB: 6/19/1972 Page #: 1 SS#: ***-**-6522 PATIENT NAME GLAZER,CIIAD SEX M AGE(YRJMOS.) 41 / 4 PT. ADD.: 320 WEST SHADY LANE Enola PA 17025-0000 DATE OP COLLECTION TIME I DATE RECEIVED DATE REPORTED TL'IE 10/21/2013 10:46 l 10/22/2013 10/22/2013 11:14 i 855 Oct 28 201i1 02:08pm P002/006 Phone: 800-631-5250 CLINICAL LNFORItMATION CD -10110429452 PATIENT ID. 19654652.2 PHYSICIAN W. NPI BUSH W 1982636841 ACCOUNT: William B Bush 5100 Lancaster St Harrisburg PA 17111-0000 ACCOUNT NUMBER: 37685183 TEST RESULT LIMITS LAB Comp. Metabolic Panel (14) Glucose, Serum BUN Creatinine, Serum eGFR If NonAfricn Am eGFR If Africn Am BUN/Creatinine Ratio Sodium, Serum Potassium, Serum Chloride, Serum Carbon Dioxide, Total Calcium, Serum Protein, Total, Serum Albumin, Serum Globulin, Total A/G Ratio Bilirubin, Total AlkaliD.'e, Ph'o's hatase,:: S AST (SGOT) ALT (SGPT) 93 12 0.87 107 124 4 140 3.8 103 2 9.9 7.3 4.8 2.5 1.9 5 9 L 9 \hjtA144-5 �� 142 121 49 Lipid Panel With LDL/HDL Ratio Cholesterol, Total Triglycerides HDL Cholesterol Comment According to ATP -III Guidelines, HDL -C negative risk factor for CHD. VLDL Cholesterol Cal 24 LDL Cholesterol Calc 69 LDL/HDL Ratio 1.4 Cardiovascular Risk Assessment Interpretation Note For Interpretations, please refer to Litholink CDS Patient Report_. PDF Image mg/di mg/dL mg/dL mL/min/1.73 mL/min/1.73 mmol/L mmol/L mmol/L nmol/L rng/dL g/dL g/dL g/dL mg/dL 'lU/L IU/L IU/L mg/dL mg/dL mg/dL 65 - 99 01 6 - 24 01 0.76 - 1.27 01 >59 >59 9 - 20 134 - 144 01 3.5 - 5.2 01 97 - 108 01 19 - 28 01 8.7 - 10.2 01 6.0 - 8.5 01 3.5 - 5.5 01 1.5 - 4.5 1.1 2.5 0.0 - 1.2 01 44: -' 102. 01 0 40 01 0 - 44 01 100 - 199 0 - 149 >39 >59 mg/dL is considered mg/dL mg/dL ratio units a 5 - 40 0 - 99 0.0 - 3.6 01 01 01 01 02 02 LAB: 01 RN LabCorp Raritan 69 First Avenue, Raritan, NJ 08869-1800 DIRECTOR: Araceli B Reyes MD Pat Name: GLAZER,CHAD Pat ID: 196546522 Speck: 294.425.4383-0 I Sec' #: 855 Results are Flagged in Accordance with Age Dependent Reference Ranges Continued on Next Page LCM Version: 03.26.01 LabCor .aboraory Camarillo, of Amara DR Bush Fax:717-561-8388 Oct 28 201d 02:09pm P003/006 LabCorp Raritan 69 First Avenue, Raritan, NJ 08869-1800 Phone: 800-631-5250 SPECIMEN 294-425-4383-0 TYPE S PRIMARY LAB RN REPORT STATUS COMPLETE Page #: 2 ADDITIONAL INFORMATION SS#: m** -**-6522 FASTING: N PHONE: 717-635-9899 DOB: 6/19/1972 PATIENT NAME GLAZER,CHAD SEX • AGE(YR./MOS.) 41 / 4 PT. ADD.: 320 WEST SHADY LANE Enda PA DATE OF COLLECTION TIME 10/21.2013 10:46 17025-0000 DATE RECEIVED 10/22/2013 DATE REPORTED TIME 10/22/2013 11:14 855 CLINICAL INFORMATION CD- 10110429452 PHYSICL4N ID. BUSH w NPI 1982636841 PATIENT ID. 196546522 ACCOUNT: with= B Bush 5100 Lancaster St Harrisburg PA 17111-0000 ACCOUNT NUMBER: 37685183 TEST RESULT LIMITS LAB LAB: 02 ($ Litholink Corporation DIRECTOR: Mitchell Laks S PhD 2255 N Harrison Street Ste B, Chicago, IL 60612-4670 Pat Name: GLAZER,CHAD Pa11D: 196546522 Spec #: 294-425-4383-0 Seq 4: 855 Results are Flagged in Accordance with Age Dependent Reference Ranges Last Page of Report LCM Version: 03.26.01 DR Bush Fax:717-561-8388 Oct 282011 02:,09pm .P001/006 i `• RATE OFSIRTM': • !0ENOER .: DATEOF.SERVICE:'� ;PHYSIEfAN.'.: 2.01'<.1d%?.1%2d1:3: •61151 •;- = ' CBbibtp AcoburrF 6'•37§$51•8 Accessions: 29442543830 DISCLAIMER: These assessments and treatment suggestions are provided as a convenience in support of the physician -patient relationship and are not intended to replace the physicians clinical judgment They are derived from the national guidelines In addition to other evidence and expert opinion. The clinician should consider this information within the context of clinical opinion and the Individual patient. SEE GUIDANCE FOR CARDIOVASCULAR RISK ASSESSMENT: National Hear; Lung, and Blood Institute's Third Report of the NCEP Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (ATP lit) (200/. NIH publication 01-3670), Brunrell et al (Diabetes Care. 200.3;31(4):21.1-32), and Contois et al (Clin Chem. 2009;55(3):407-419). Note: Please refer to your LabCorp Report for all results as well as any test-spec/fie and speclmen-speciflc comments. Cardiovascular Risk Assessment Analysis & Treatment Suggestions Patient Risk Assessment Current available clinical information suggests the patient's risk category is at least LOW. tf the patient has two or more major risk factors, the risk category is intermediate. If the patient has CHD or a CHI) risk equivalent, the risk category is high. Thyroid disease, nephrotic syndrome, and liver disease are all causes of secondary dyslipidemia. Consider evaluation if clinically indicated. Patient was not fasting, interpret assessment and treatment suggestions with caution. Therapeutic lifestyle changes are always valuable to achieve optimal blood lipid status (diet, exercise, weight management). Patient Risk Category Select one patient risk category (based upon medical history and clinical judgment) for lipid assessment and treatment suggestions. in cardiovascular disease prevention, the intensity of risk -reduction therapy should be adjusted to the level of patient risk Additional risk factors such as personal or family history of premature CHD, smoking, and hypertension modify a patient's goals of therapy. '7 - PATIENTS RESULT ANALYTE/ RESULT LDL -C 69 mg/c11. non -HDL 93 mg/dL Lipid Assessment Treatment Suggestions Patient Risk Category (select one) v LOW 160 V GIESIMEMEIND 190 LDL -C is at goal. Non -HDL -C is at goal. Lipid status is optimal. INTERMEDIATE v HIGH v 100 130 70 100 V 130 160 100 130 LDL -C is at goal. Non -HDL -C is at goal. LDL -C is at goal. Non -HDL -C is at goal. Although patient Is at goal for both LDL - C and non -HDL -C, consider measurement of LDL particle number or Apo B to adjudicate need for further LDL lowering therapy. Although patient is at goal for both LDL - C and non -HDL -C, consider measurement of LDL particle number or Apo B to adjudicate need for further LDL lowering therapy, /Z ffi-®�= ------- — mew V MI rApjf. Learnr.ory Corporation of Ametier — Mitchell S. Lake, PMD Laboratory Director CLiA# 1400897314 Llthoilnk, A LabCorp Company 2250 west Campbell Park Drive Chicago, Illinois 50612 800 338 4333 Telephone 866 3617939 Facsimile www.litholink.com Version: 6.10.3.18 Printed: 10/22/2013 Page: 1 of 2 Oct 28 2014 02:09pm P005/006 Patient Results Summary NiL llhiltii l bColp:Account.# 7 Cholesterol comes in different forms and has varying effects on your heart health. Some cholesterol is "good" and not known to cause disease, this is HDL. The rest of cholesterol causes disease by clogging your arteries, this is non -HDL LDL cholesterol is the largest component of the non -HDL cholesterol. Lowering your levels of "bad" cholesterol will lower your risk for disease. • LDL cholesterol (LDL -C) is the largest component of the non -HDL cholesterol ("bad" cholesterol). • non -HDL is composed of many different types of cholesterol (not just LDL -C) and high levels cause disease. The level to which your LDL must be lowered depends on the risk for developing heart disease or having a heart attack. The higher your risk for heart disease, the lower your LDL goal. ❑ Heart and/or vascular disease High blood pressure Diabetes Chronic kidney disease =YOUR RESULT Test/ Your Results LDL -C 69 mg/dL non -HDL 93 mg/dL 0 Cigarette (tobacco) smoking • ❑ Low HIDL (men less than 40 mg/dL, women less than 50 mg/dL) [] Family history of early onset heart disease ❑ Man over 45 years or woman over 55 years P<ra.�.: Aiwi Y $.4',Z;,-1.:4-,) i:rt V 160 V 190 Change your diet: limit saturated / trans fats and cholesterol, increase fiber ❑ Exercise ❑ Lose weight 0 D :Intermediate V 100 130 CZIMMEMEMZIO 70 100 130 160 100 130 Your Target' (as seleCtedl.by Your, lciari b,�isll-` :,sem $!;;A -a4 w"Vf''N ❑ Control any other medical conditions: such as diabetes, high blood pressure LI Visit your doctor as scheduled and obtain all follow-up tests/treatments recommended ❑ Take all of your medications your doctor(s) have prescribed • • A. ,' DISCLAIMER:You should discuss this Information with your physician. Litholink does not have a doctor -patient relationship with you, nor does it have access to a complete medical history ore physical examination that would be necessary ror a complete diagnosis and comprehensive treatment plan. Neither you nor your physician should rely solely on this guidance. REFERENCES; National Heart, Lung, and Blood Institute's Third Report of the NCEP Expert Panel on Detection. Evaluation and Treatment of High Blood Cholesterol in Adults (ATP III) (2002. NIH publication 02-5215): National Heart, Lung, and Blood Institute's Your Guide to Lowering Your Cholesterol with TLC (2005, NIH publication 06-5235) Laboratory Corpors1cn of Air,erl Mitchell S. Lake, PhD Laboratory Director CLIA# 1400897314 Litholink, A LabCorp Company 2250 West Campbell Park Drive Chicago. Illinois 60612 800 338 4333 Telephone 866 361 7939 Facsimile www,litholink.com Version: 6.10.3.18 Printed: 10/22/2013 Page: 2 of 2 ;S . ,-• noLfa a J'k4.1c...r I: 3 r.?sc r . u- ' -G v ' Jam-'- C h 4-. • o 'L 5 X• G i,t.'r •1, • "� & ase No_ " ' ' R8�feried DR Bush Fax:7 S. Oct .28 20 02: 7'144 •Pati hes;Nerve ' r' InsuraT ce pm P00? Date . • • .: ` '' O'ocupation Age aex S.M:w0. "•' DATE' Mo.; w *6F' ,compuk it APD 710.NAL HISTORY: PHYSICAL FIN INGS MEDICATIONS. C•hie f c.om ecw qT, sy gNIw ca hive:' tat 'fo nscis wick C„r�:1fi few res tktoiy, $ trOtii ?.::. skm, aeurofogicai pSYcho *ttscUIeek[elit;;}; Tnyr r• t, era:1;:' Nle, 'Cp Aorcrint-lit is > t><ours h d; o 'acute • dis • iA are rie$r,.the tragus;. exterltR1%Canal;': ; • ttc . btnates are. normal; tlse phti ryri re;trt good rep*iic� ar. *! atter are wit ands aft'palraxpjtite ck no ni ujt ie+ ..file:Without. thYd'roi+i'itnega)yor;JV» Norrn tr ttlil'eaepILus. irate is tigr. • o•'s,useultstion an ::Thi''__ rt) perces* N ortst a3'118 •resp roto rats •tferiphecoI vs eul • . , a:r: ;Nc'rfpgl':tir•'at;3a► :. � .rapsste, t�.alav: , tlorsohs pedis pulses bitatersl x�o ztzLirttrtiTs':'Na eAt'aia'tiegQ tn�.,� tentioit";,;. '1.ea•5se$ ;t?+aasczte :: No evithace.tzt'ltei�tii :rrtaal_• eis ne"R,,;.�ct `1 Trio . $a . Q�bR.i ..' •: •- '.' , � 'sl"'•�`i► �endea•oess �►e.�i arr'rebouncl;: T.tieie': . m eie Via.=.• ; is tti3) rar't?f motion_ There ".s u Kh is negative: No varicosities: u 'MUMede _ Intoe Ythreina.,, phatics:.egative•surve t. a I groin elate Skin: i�o'lesi u•ce. o;f bleeding or eccynsosis, No I�teurologica1: Su'Iv rnai. 1, ' •�tegative upils. areeq».at d;reacti to ugnt, the Crania'1 nerves are ilexes, .ti�ere' are n foc l' tie#icify the IS alert end''o.i�ienred and aII'sph • is:no`;nal;,Bomb rg's test 'is, Al Dec 2912 05:44a p.3 BLGRPA ERIE INSURANCE EXCHANGE P Erie T Insurance FAMILY AUTO �PSI Group AMENDED DECLARATIONS 01 * * EFFECTIVE 04/10/12 ATTACH THIS TO YOUR POLICY. MR\100 Erle lnc Pe. EFJn, PA 1E530 REASON FOR AMENDMENT - MULTIPLE CHANGES POLICY ;•�.,,,H,:;_, ;:--:;-;:--1ENT: :1T M.�. POLIIM E ;; �.�.,._:,; AUNIBB:- ... ....-- AA7172 CONSOLIDATED INS INC 10/07/11 TO 10/07/12 Q10 0704846 H ,.,..-- T .::. A �. , � ..� :. �IAI9�I41 t�i��FI? :TA � ._..• _ ._r. -„-_u .�-.r _ :_..,:.t��t�3EFI i "i3P - - ,.... CHAD M GLAZER & LESLIE J LOPER GLAZER 320 SHADY LANE APT 4 ENOLA PA 17025-2258 AS LISTED BELOW : AGENT - CONSOLIDATED INS INC F• AGENT PHONE - (717) 838-1391 ************************************************************ * CONGRATULATIONS! A PIONEER * BEEN APPLIED TO YOUR POLICY *********.************************************************ ************* *****>*s******************************************************* * YOUR COLLISION COVERAGE AND DEDUCTIBLE * AUTOS YOU OR A RESIDENT RELATIVE RENT * SUBJECT TO LIMITS, TERMS AND CONDITIONS ****************************************************************************** ITEM 4. AUTOS COVERED 225 N RAILROAD ST PALMYRA PA 17078 1315 EXPERIENCE RATING CREDIT HA PREMIUM. APPLY TO PRIVATE PASSENGER FOR 45 DAYS OR LESS. THIS IS * IN THE POLICY. * ST TER PHY LIOTCMCL RATINGCLASS PA 4D 0717 A1ASM PA 4D H 0509 A2ASM PA 4D 0814 A1BLM PREMIUM OR INCL, IS SHOWN AND ANNUAL PREMIUMS ARE AS F #1 #2 #3 *****GOOD DRIVER RATES TO ALL PRIVATE PASSENGER VEHICLES. 95 93 110 88 86 102 113 87 131 9 7 12 2 1 2 20 15 20 104 80 99 75 195 4 432 $ 1,554 644 478 $ 174 EXCEPTIONS TO DECLARATIONS AF¢A03 06/11, UF -6853 07/10*I ..... ___ * * ** DDP MM39 FM31 MM39 FOR THE LLOWS- APPLY***** --- ITEMS AUTO YR MAKE VIN 1 95 CHEV S10 PICKUP 1GCCS1448SK170060 2 03 VOLK JETTA GLS 3VWSK69M83M108120 3 06 SATU ION 2 1G8AM15F76Z111283 ITEM 5. INSURANCE IS PROVIDED WHERE A COVERAGE. COVERAGES, LIMITS M EQUALS THOUSAND $ --- THE FULL TORT OPTION APPLIES LIABILITY PROTECTION - BODILY INJURY $100M/PERSON $300M/ACC PROPERTY DAMAG $100M/ACC FIRST PARTY BENEFITS - MEDICAL EXPENSE $100M INCOME LOSS $1M/MONTH, $15M MAXIMUM ACCIDENTAL DEATH $55M FUNERAL BENEFIT $22 GG UNBOODDURNDJ $100M/PERSOS N $300M/ACC-UNSTACKED OVER GE- UNDERINSURED MOTORISTS COVERAGE- BOD pHYODCINJAL DAMA0M/PERSONGE G$300M/ACC-UNSTACKED S - COMPREHENSIVE - $50 DED COLLISION -_$250 DED OPTIONAL COVERAGES - ROAD SERVICE TOTAL ANNUAL POLICUAL YMPREMIUR MCH AUTO ADDITIONAL CHARGE DUE TO THIS CHANGE ITEM 6. APPLICABLE POLICY ENDORSEMENTS ALL AUTOS - FAP 03/07, AFPF01 03/07, AUTO 1 - AFPUO1 11/10. AUTO 2 - AFPUO1 11/10. �6��qY���;$ AUTO 3 - AFPUO1 11/10*._ —SEE REVERSE SIDE"' Y AGTSAG 04/10/12 MEDICAL RECORDS LESLIE LOPER-GLAZER PLAINTIFF'S EXHIBIT II C.• w. �a e , Oct 28 201d 02:28pm .P005/018 :.ADO1T{.ONAA1. HISTO'AY; PHYS/CAt Ff 611N! THE HETRICK CENTER You have a choke for Physical Therapy...c hoose us! 500 North Union Street 1300 Bent Creek Boulevard 20 North Barbara Street 845 Sir Thomas Court, Suite 11A Middletown, PA 17057 Mechanicsburg, PA 17050 Mount Joy, PA 17552 Harrisburg, PA 17109 Office: (717) 944-2225 Office: (717) 796-2225 Office: (717) 492-0303 Office: (717) 652-4002 Fax: (717) 944-0932 Fax: (717) 796-2229 Fax: (717) 492-0309 Fax: (717) 652-4005 September 6, 2012 Middletown RE: Leslie Glazer DOB: 03/07/1980 PI CLINICAL HISTORY Ms. Glazer presents to The Hetrick Center of Harrisburg today with chief complaints of neck pain, upper back pain and lower back pain following a motor vehicle accident which occurred on 09/02/2012 for which she was a restrained passenger. She notes that she was stopped at a red light and was hit directly from behind causing a rear end collision. Her head was jerked forward and backwards rather quickly, noting immediate pain in the neck, the upper back, mid back and some subsequent pain in the lower back. The evening of the accident, she was not seen in the ER. She does have a history of neck pain and upper back pain but she notes feeling fairly well prior to the accident occurring on 09/02/12. Onset of the pain was sudden. She did retain consciousness. She notes hitting her hand on the inside of the car. She did not hit her head on the window either way but she did impact the head rest subsequent to the accident. She notes that the pain quality today is a dull achy sensation with very intense stiffness and throbbing. The pain severity is a 7- 9/10 on a Verbal Borg Scale. She did take medication this morning and still reports a 7/10 pain. She notes that the pain has been worsening and is now extending into the left arm with some numbness following the MVA. The pain has been persistent since the time of the accident and is currently constant. It is exacerbated with any sort of lifting, even lifting up her pocketbook. Any sort of motion of her C-spine, tends to increase her neck pain significantly. She also notes that wearing heels increases her lower back pain. She is having moderate difficulty performing most of her ADL activities at this time. She put on a heat patch over the cervical and upper back which gave her some comfort but no real pain relief. She has been taking Vicodin, which has quieted the pain mildly. She notes having a headache which has been a constant throbbing behind her right eye. She notes no migraine type symptoms, i.e. photophobia or visual disturbances. She also took a Soma to help her sleep prescribed by her PCP for sleeping and Vicodin for whiplash. Please see her intake for further details surrounding the automobile accident, as well as her medical history. PHYSICAL EXAMINATION Examination reveals a 5' 2" 135 pound female, Caucasian, with normal blood pressure today tested at 120/68 seated on the left side. She is pleasant, well oriented and in a moderate to severe amount of neck and upper back pain. Postural examination reveals a right handed individual with an elevated right shoulder, right rotated head, left laterally flexed head and an elevated left ileac crest. Range of motion study of the cervical spine was grossly restricted with flexion 5 degrees, extension at 5 degrees, right lateral flexion at 15 degrees, left lateral flexion at 10 degrees and SPECIAL NOTATION: The Hetrick Centers CHIROPRACTOR SOAP NOTE Tax d: ��5- 40289 DATE: Last Name: '�� i S: Recurrent cute Sub -acute 1300 Bent Creek Boulevard Mechanicsburg, PA 17050 717-796-2225 20 North Barbara Street Mount Joy, PA 17552 717-492-0303 500 North Union Street Middletown, PA 17057 717-944-2225 845 Sir Thomas Court Suite IIA, Harrisburg, PA 17109 717-652 002 First Name: eon Exacerbation Chronic New complaint Wellness MI: D.O.B: �`7//6 D TE OF ONSET: VAS Pain Scale 1 2 3 4 5 ee DT. Osseous Findings & Osseous Treatment (Mani ulation) C 0 l T I L 1 2 3 P R L SR L B BP Extraspinal: 36U15� 45Z 7c 9 10 11 12 • • E P FSE P FSE P FSE P G G H T ANT /D SOT D TH D TH D D T D TH D TH A A' A A A A' Soft Tissue Findings & Non -Osseous Treatment : Tenderness/1 ®3 4 C T L EXTR / Tonicity 1 al 5 S-A / S -M / S -P LS . SCM / T -M / T -L ) Ect FR TP R SA T -MA / T -M. SS IS P -MA / P -MI W -F / W -E telD E qTlr";( 1 2)SCS FR LP QL LD P G —MAX / G—MED / G—MIN TFL BTHQ GAS PF (R / L) E TP (1 2) P SP FR OTHER: E TP j 2) P SP FR • 1/A A/R M/R Other. DMM PNF Time: Min. Manual TXN Tim Min. IFC RS SB PRE I 5"--- Min (Patient Tolerance) 1-1 80-120 0-150 1-120 10-10 10-50 USP USC Min @ Watts / CM 2 20/5% 40/10% 60/15% 80/20% 100/25% COLD t 5-- Min Skin Condition :re -Norma �o orii Today's Treatment: Well Tolerated N POST TX VAS CYLCase Management Towards Resolution`/ Stability of Patient's Condition: RED FLAG: Yes No The patient's current complaint, past medical history; prior surgeries, medications, allergies, family history, social history and review of systems fined in the patient's medical record and these were reviewed today. Cont. TX Plan Modify TX Plan: End TX Plan ' Re-eval.Date: O Anticipated Treatment Plan: ' Days Weeks / Visit # of PRN O New Exercise Program Min. (See handout): O Nutritional Support: ❑ Home Instructions: 0 Taping / Strapping: Min Type of Tape Used: ❑ DME / Supports / Appliances: ❑ Studies: Rationale: ❑ Refer for outside services: Rationale: RECQRDS SENT Body, Region SEP 0/2u12 ❑ All exam information entered in ASHN tx. plan (See .ASHN form) Highmark tx. plan (See HM form) ❑ Other: Consulted with the patient on t ?/1 ificatio ing:. mi emov N + ' ional Counseling / Hea OAT Scores/Symptoms b i)IAGNOSId: ' Omit: 30 —50 'o by next evaluatio Other: / Alter Ergonomics @ World Home / Lifestyle Contrast/ RICE / Smoking Cessation Today's Not Signature: Lam_ D.C. 0 Bartakovits ODavid Carbo DC 0 Mary Colman DC 0 Scott Colman DC ❑ Timothy Duke DC 0 Paul Hetrick DC dward Hevne a C 0 Charlene Hobbie DC 0 Ashley Viele DC ischarg Dictat Highmark / ASHN TX &Progress Note .ACN form THE HETRICK CENTER Leslie Glazer Page 2 of 3 September 7, 2012 bilateral rotation at 10 degrees, all causing moderate to severe general neck and upper back pain. Orthopedic testing was positive for pain reproduction / increase with maximum cervical compression. Noted over the C7 through Ti level along the midline. Bilateral Jackson's compression was positive for pain noted over the C7 through Ti area and radiant pain to the proximal trap. She had some tingling sensation in the left upper extremity with left Jackson's compression test. Dermatomes over the C7 through Ti levels were normal to pinprick and light touch. Soto -Hall test was also positive for severe pain noted by the patient between C5 and C7. Deep tendon reflexes tested normal in the upper extremity with a 2/5 bicep, brachioradialis and the tricep. Myotomes were also normal and brisk with a 5/5 at the deltoid, bicep, wrist flexor, tricep, wrist extensor and finger abduction/adduction. Range of motion of the lumbosacral region as restricted and caused pain, generally in the low back but worse of the sacroiliac joint. She also notes having pain in the hip flexor with extension at 10 degrees. Flexion at 30 degrees reproduced lower back pain. Right lateral flexion at 15 degrees. Left lateral flexion at 5 degrees. Right rotation at 10 degrees and left rotation at 15 degrees. Heel to toe walk was normal. Orthopedic testing was positive for straight leg raise bilaterally, left at 40 degrees increased lower back pain and the right side at 20 degrees reproduced lower back pain, predominantly in the right sacroiliac joint. Valsalva maneuver also reproduced mild increased lower back pain. Myotomes in the lower extremities tested strong and brisk bilaterally at 5/5 hip flexor/extensor, hip abduction/adduction, knee flexion/extension and ankle dorsi/plantar flexion. Deep tendon reflexes were also normal with a 2/5 response at patellar and Achilles. She has observable muscle spasms in the trapezius muscles bilaterally. Hypertonic muscles in the cervical spine with a left with a +3 and a right side witha +2. Multiple trigger points throughout the trapezius muscles were also increased in tenderness to digital pressure. The patient was unable to perform any isometric resistance today due to pain. TREATMENT PLAN The patient was treated today acutely With ice, electric muscle stimulation, manual traction to the C-spine, light passive stretching to paraspinals. in the C-spine and the appropriate specific adjustments to fixation levels. Chiropractic palpatory findings did reveal spinal fixation / vertebral subluxation complex as noted in her SOAP note. The patient will be seen over the next two weeks, three times a week followed with a re-evaluation to determine current status and need for future care. Home instructions include icing the area, continuing medication if needed and prescribed by her PCP. Pain free ranges of motion in the C-spine as well as the lumbar spine one to two times per day. Avoid lifting, pushing or pulling activity times approximately one week. I have also recommended that she sleep in a more neutral position and more on her back while she is in an acute amount of pain. Goals Of treatment are to reduce pain, restore normal ranges of motion, muscle tone and restore the patient to anOrmal ADL / pre -accident status. Diagnosis is clearly stated in the SOAP note. DIAGNOSTIC STUDIES A plain film radiographic study was secured of the cervical region consisting of a neutral lateral and A -P open mouth, and an A -P thoracic cervical view. The cervical neutral lateral reveals occiput through C7. There is a total loss of the normal cervical lordosis with a mild reversal in the mid portion of the C-spine. There are seven THE HETRICK CENTER Leslie Glazer Page 3 of 3 September 7, 2012 contiguous normally -shaped cervical vertebrae. Disc height loss is noted in the mid portion of the spine between C4 and C5, noted as mild. The facet joints appear to be unremarkable. No indication of fracture, dislocation or gross pathology seen in this view. The A -P open mouth reveals the occiput/C1/C2 complex, the dens is centrally located and intact. Adequate joint spaces are maintained between occiput and Cl bilaterally, as well as Cl lateral masses and the body of C2. There is no indication of fracture, dislocation or other bone gross pathology on this view as well. The A -P upper thoracic and cervical view reveal clear long apexes bilaterally. There appears to be a mild curve in the upper portion of the T-spine with a left concavity. Mild disc height loss is noted between C4 and C5, as well as C5 and C6. Uncinate processes are unremarkable. Normal symmetry. No indication of fractures, dislocation or other gross pathology seen in this view. RADIOGRAPHIC IMPRESSION Is that of one with a total loss of the normal cervical lordosis with a mild reversal in the mid- portion of the C-spine. Disc height loss as noted in the body of the report. It is my professional opinion within a reasonable degree of chiropractic certainty that the subjective complaints put forth by the patient, my examination findings and the OAT forms, do directly correlate with the automobile accident which occurred on 09/02/2012. The patient is in need of medically necessary chiropractic care to help correct and reduce pain, and restore normal function. The patient will be seen over the next two weeks, three times a week, followed by re-evaluation. I did advise her to ice 5 minutes x 5 sessions in the C-spine and upper thoracic spine. The patient will follow up in appr 'mately two days for additional treatment. p-- G�c dwar. . Hevner, D.C. EL THE HETRICK CENTS PERSONAL INJURY QUESTIONNAIRE PATIENT NAME ( Z- ':- (2----- DATE OF BIRTH 1)6') ii �//Z t f Y • Date of Accident? �:'' G:%_}i,,Time of Accident? ` i`_'> r'}�'�� ! _ / % - , 8 n /., t ''� )'` r' J • Location of Accident: t'_ i'r 4-. .a -,S ` ,}t,%� _ hv(`�-' -Li /; k. ell "i(-, 1�'U • In your own words, how did the accident occur? s ' 1- z 1'z%d 1 R elf/it - (�j% I� -i': ..'NL... 1 t "i'. • Were you the driver or a passenger in the automobile? ! .. =; J If you were a passenger, what position were you sitting in the automobile? • How many people were in your vehicle? Other vehicle(s)? • What is the make, model and year of your automobile? ,9a124,) S i';1-OVZ . ::1:,, 5\,..) ''f.<. • What is the make, model and year of the other vehicle(s) ,4-46 I / ,;, 6 z� ; �•: e' . z, • What were the road surface conditions (thy, wet, snow, ice, etc.)? �t ) ''•IN • How fast were you traveling? C J-�`, `'-�' 6 ._. _.. ; The other vehicle? ,1.-.:6-,/ .. - ! hg3 k • What type of damage was done to your vehicle? ;e -C =(1:1:0=) --i':x;)v -v ==i , • What type of damage was done to the other involved vehicle(s)? d\ NIQ...... • Were you aware the accident was going to occur, did you see it coming? Yes X No • Did you hear any tires screeching? Yes )- No • If you struck the vehicle in front of you, did you hit it straight on, off to the left or off to the right? • If you were hit from behind, was the impact more from the center, or more to the left or right? •C • Was your foot on the brake at the time of impact? )(-. Yes No. If yes, did your car move forward after impact? Yes `K, No • Where did your vehicle end up after the accident? (I.e. did not move, moved slightly, ended in a ditch, etc.) `i► , `-) 4, 1-11/10,1'-'------.. - • Where did the other involved auton1obile(s) end up after the accident? A --'\,..e 61, 1/ - „-Y Y'4w) • Did anything in the vehicle strike you? Yes No. If yes, what and where? • What was the position of your head (looking/turned to the left/right, looking straight ahead, looking in the rearview mirror etc.)? WI 1 -61(714 - Page 1 of 4 • What was the position of your hands on the steering wheel at the time of the accident? y - (i.e. l0 & 2 o'clock) /i% <' `C • What was the position of your legs/feet? k • Were you sitting straight up? . N, Yes _ No. If you weren't, were you leaning to the side (Right or Left), slumped in your chair, etc.? • What was the distance from the back of your head to the headrest? /„ C inches)? What was the height of your headrest? 01 k Q • Were you wearing the appropriate seat restraints? ` Yes _ No. Were you wearing: shoulder restraints, lap restraints or both? -1--)b • If you were wearing eyeglasses/sunglasses, did they remain on your face? Yes X. No. Did you have to readjust your glasses after impact? Yes • Were you wearing any accessories on your head? Yes X. No. Were the accessories still on your head after the accident? Yes No. What accessories are you referring to? • Do you have any pictures of your vehicle following the accident? $- Yes No No If yes, which direction was your head whipped? f:'.."ratio • • • Did you have to be extricated out of the vehicle? Yes , No. Were you able to get out of the car on your own? Y., Yes _ No • Were you taken from the accident via ambulance? Yes`;4., No. Were you examined and/or treated by an emergency medical crew at the site of the accident? _Yes) No If you went to the hospital, whether via ambulance or on your own, where were you taken? 16,/ _ 3 No. 04-\• Do you remember your head being whipped back and forth? , ,Yes Did your head strike anything in the vehicle? Y'.Yes No. If yes, what? ¢t I ' j Were your airbags released? Yes No • Have you been examined/treated by any other health care providers? Yes • No. If yes, please tell us who?/when?/where?/how often?/etc. I -i %'r - f 7 rtl f c J I 'l l @�+ l t • Have you been prescribed any medications for conditions sustained in this motor vehicle accident? Yes or No. If yes, what have you been prescribed? L,;. 2 3 t fiY'l A1(2 -r F 1-1 .���o; sh s:.i:`'N'?i' ,�,�,� i5c�-•�.:.-.,'1 (4-1)0‘•47f e:f • Have you had any special studies (x-rays, CAT scans, MRI's, etc.) performed for this accident? Yes or No. If yes, what? 0,i) Page 2 of 4 • Did you have any visible injuries immediately after the accident? Yes or No. If yes, what? 1\1 U Do you have any pictures of the visible injuries? _Yes '7‘. No. If this is more than 3 days after the accident, have you noticed any bruising on your body? _Yes or No. If yes, where? • Have you eygr been involved in a motor vehicle accident in the past? If yes, what date? Nature of the accident i-.-.)/T,P.L-civ _tp, • Do you remember everything from the time of the impact until after the impact? KYes No. Did you lose consciousness as a result of the accident? _Yes • Have you noticed any visual disturbances as a result of the accident? _Yes x; No. Have you had any ringing of the ears? Yes No. Anything else? ij-b11::(\tt...--: • Were you nauseated as a result of the accident? _Yes No. Did you vomit within the first 24 hours following the accident _Yes No. Were you dizzy? _Yes X No. • Are you experiencing any jaw pain? _Yes No. No. Right / Left / Bilateral. • What symptoms do you have as a result of the accident (i.e. neck/back pain, arm/leg pain, headaches, extremity complaints, etc.? IVe 04- ,J6) vz -c?1. 11 R f()L,.) J Describe your pain i.e. burning, sharp dull,.etc. h ftrt-\ 64,A iv -pc Do you have any radiating arm or leg pain? l(Yes No. • Are your symptoms? _Getting Worse Staying the same Getting Better • Does anything make your pain better or worse? Describe: Aki> • Is your pain worse with coughing, sneezing or going to the bathroom? Yes No. ' • Have there been any changes in bowel/bladder function since the accident? Yes /: No. • Are you having any problems with memory or concentration as a result of your motor vehicle accident? Yes No. Describe: • Did you bear anything pop, snap or tear during or after the accident? Yes • No. • What is your current pain level (0-10 scale), with 0 being no pain and 10 being the worst pain that you could ever imagine?/;2' 7/10 When you feel the best, what is your pain level?; -"i /10 When you feel the worst, what is your pain level? //j /10. • Are your current symptoms with you 25%, 50%, 75% orr100%of the time...Mark down which symptoms are with you via those percentages? It (I (41 Page 3 of 4 3. 3 , - 00% 75% 50% 25% Did you have any complaints prior to the accident you were involved in? 4Yes _ No. If yes, list these areas and write what the pain level (1 to 10 ) was prior to the motor vehicle accident at its best, worst, average -77 - :7) • Have you worked since the accident? .4 Yes _No; If yes, _ FT PT KIntermittent • If yes to above, are you on limited duty? •)4Yes NO. Describe: ;I:. fci • Are you having difficulty performing your daily activities? XYes _No. If yes, what ' are you having difficulty performing? I.VA-1) (I j'itc-L, • Are you having difficulty sleeping since the accident? ''Yes _No. Describe: i 1.1` '-i l.- \:.'-< --.''-r i'" C i.,-1 ii, 1 ) ii ) I -T n (7i_ ( (),:ti‘Vvi-ri 4--- _i _.,, • Is there anything else we have not asked you that you feel is pertinent to this case? Patient's Printed Name: WD 7 / r Patient's Social Security Number: I have answered the abov,e4uthfully / 4 ! • Patient Signature d to the best of my knowledge, Provider Signature Revised: 03.05.03 Page 4 of 4 Date Da The Hetrick Center Acne A Poke fa role Plrxa 1Mim»'—Clwme Ug 500 North Union Street Middletown, PA 17057 Tel: (717) 944-2225 Fax: (717) 944-0932 Thee 20 North Barbara Street Mount Joy, PA 17552 Tel: (717) 492-0303 Fax: (717) 492-0309 1300 Bent Creek Blvd Mechanicsburg, PA 17050 Tel: (717) 796-2225 Fax: (717) 796-2229 845 Sir Thomas Court Suite IlA Harrisburg, PA 17109 Tel: (717) 652-4002 Fax: (717) 652-4005 at Release ®rer© Patient Name: G tra zc� (�S 1t' a Date of Birth: 3 ? • ka Diagnosis/Codes: cry4, 01 1, 424. ir% Date of Order: ? /d -` _- # -. /WK Weeks Date of Reevaluation: a Perform Myofascial Releaseror Massage (97 ' _v. r 30 minutes to include the following: Trigger Points: jndef'Points eep Tissue: oft4 tissue Release: MFR PNF:_ Active/Passive Stretching w NMT`µ;,n. CT: Other: Treatment Area: Cervica. L`/ i° horacic LE (L/R): UE (L/R): Muscles/Muscle Groups/Soft Tiss.;aes: CP SO Mi) LD TP R SA T(Ma/Mi) SUB SS IS P(Ma/ LP QL G(Max/Med/Min) TFL P H(F/IN/EX) DELT BI TRI CB B W -F W -E BR ITB HS(BF/SM/ST) Q(RF/VM/VL/VI) ADD(Ma/LoBr) PER(Lo/Br) TA GAS SOL PF Other: For Massage Therapist: Provider: /n~ Revised: 12.18.06 D.C. ISPECIAL NOTATION: I The Hetrick Centers 1300 Bent Creek Boulevard Mechanicsburg, PA 17050 717-796-2225 CHIROPRACTOR SOAP NOTE 20 North Barbara Street Mount Joy, PA 17552 717-492-0303 Tax Id: 25-1640289 500 North Union Street Middletown, PA 17057 717-944-2225 DATE: p -t0•11. 845 Sir Thomas Court Suite 11A, Harrisburg, PA 17109 717-652-4002 Last Name: G (o? e.. First Name: / el j; +? MI: D.O.B: 3.7 - S- Q S: Recurrent Acute Sub -acute Exacerbation Chronic New complaint Wellness DATE OF ONSET: LestL { A. Lr CI) N 0P bu+ chat L•A.LP T e •Qon, . ,v -tar (.I inui-cti. OD 'I •9-G-ta S.,-, ,k.V.a . VAS Pain Scale 1 2 3 4 5 6 7 8 9 10 See DT. 0: SA_ t. L.. an— 0 i - 9-6.1a. See DT. Osseous Findings & Osseous Treatment (Manipulation) C 0 1 (11 3 4 t=p13 7 • FS E 7 T D TH A T I®Q 4 5Z1 7'8 9 10 11 12 ♦ F -§-ri, D TH A L 1 2 3 C)o P R L B SR L B BP Extraspinal: • • • F E ' G D <ID A FSE P G SOT D TH A FSE P G D TH A FSE P H D TH A Soft Tissue Findings & Non -Osseous Treatment : Tenderness/10D3 4 C T L EXTR / Tonicity 1114 5 SO S-A / S -M / S -P LS SCM / T -M / T -L 41, E ) ab FR TP R SA T -MA / T -MI SU SS IS P -MA / P -MI W -F / W -E (R / L) E TP (1 2) P SP FR LP QL LD P G —MAX / G—MED / G—MIN TFL BTHQ GAS PF (R / L) E TP (1 2) P SP FR OTHER: E TP (1 2) P SP FR I/A A/R M/R DMM PNF Time: Min. Manual TX'N Time: iYtin. MOther: IFC HV RS SB PRE : It— Min (Patient Tolerance) I-10 80-12t : i- 30 -120 10-10 10-50 USP USC Min @ Watts / CM 2 20/5% 40/10% 60/15% 80/20% 100/25% COLD 1. t' Min Skin Condition orma / Post -Norm. / Today's Treatment: Well Tolerate N POST TX VAS El Case Management Towards Resolution / Stability of Patient's Condition: RED FLAG: Yes No The patient's current complaint, past medical history, prior surgeries, medications, allergies, family history, social history and review of systems are all well outlined in the • . • - • 's medical record and these were reviewed today. New TX Pla Cont. TX Plan odify TX Plan: End TX Plan Re-eval.Date: 0 Anticipated Treatment Plan: Days Weeks / Visit # of PRN ❑ New Exercise Program Min. (See handout): RECORDS SENT ❑ Nutritional Support: ❑ Home Instructions: ❑ Taping / Strapping: Min Type of Tape Used: B. f eei(c�n2 012 ❑ DME / Supports / Appliances: El Studies: Rationale: ❑ Refer for outside services: Rationale: ,. .2. ❑ All exam information entered in ASHN tx. plan (See ASHN form) Highmark tx. plan (See HM form) ❑ Other: Consulted with the patient on the following: Limit/Remove Aggravatin: Factors / Alter Ergonomics @ Work/ Home / Lifestyle Modification / Rest Y N / IHEP / Sleep Positions / Nutritional Counselin.'< 461 Contrast/ RICE / Smoking Cessation Goals: 1 OAT Scores/Symptoms by 30 -50% by next evaluation/ Other: - DIAGNOSIS: Add: Omit: Today's Notes: P ai I. Dictated Note Discharge Dictated OAT Highmark / ASHN TX &Progress Note ACN form Signature: — c D.C. ❑ Ed Bartakovits ❑David Carbo DC ❑ Mary Colman DC 0 Scott Colman DC ❑ Timothy Duke DC ❑ Paul Hetrick DC O. Edward Hevne DC ❑ Charlene Hobbie DC 0 Ashley Viele DC 0 Jason Green DC SPECIAL NOTATION: " / The Hetrick Centers 1300 Bent Creek Boulevard Mechanicsburg, PA 17050 717-796-2225 CHIROPRACTOR SOAP NOTE 20 North Barbara Street Mount Joy, PA 17552 717-492-0303 T. . I • : 25-1640289 500 North Union Street Middletown, PA 17057 717-944-2225 DATE: 845 Sir Thomas Court Suite 11A PA 17109 . . arrisburg, 717-652-4002 1,7 Last Name: ���/;i First Name:.. ‘, 7 ,, MI: D.O.B: 1ff,"I w S: Recurrent Act' 1" Sub -acute E a erbation Chronic New complaint .. • Wellness D /E OF ONSET: L .e.5I (a e/o frar• ./� p 0 14- i nassaq�Qd 71)c, X a doy/, ,S i- C©;, i — at <'-I0 /Jt1 (Air1 ac-it.!0i ..aw-z' /aae.e._ 5'';14 -". VAS Pain Scale 1'2 3 4 5 6 7 8 9 10 See DT. o: �, n,t, 6114- scm 4.2 (.. o,:/L/ L )fJ/ .-OQ"u,1 it /3/L z .F, 5 ir. t F,, ' / i ,? 07. cl p,i-- 157. 1 E4.4- �WO, 1 ~ [d �J , .. , , , See DT. Osseous Findin_s & Osseous Treatment (Mani . ulation) C 0 1 2 4 le 7 e' I D TH A T 1a 3 N5 f)7 89%10 11 12 A T' D TH A L 1 2 3 d� , '.:G.. D.., A P R L B S R L B BP Extraspinal: V V ♦ F:: S E P G SOT D TH A F.S"E P G D TH A F'S,'E P . H D TH A Soft Tissue Findings & Non -Osseous Treatment : Tenderness/1 Z 4 C T L EXTR I Tonicity 1a))4 5 ® SO S-A / S -M / S -P LS ► / T -M / T -L ) E ..V02 OSP FR TP R SA -MA / T -MI SUB SS IS P -MA / P -MI W -F / W -E (R / E . TP (1 2) P SP : FR LP �,D(G —MAX / G—MED / G—MIN TFL B T H Q GAS PF R E a (1 2 )(. SP FR OTHER: , , E , TP (1 2) P SP FR I/A A/R M/R D I all Time: (t Min. Manual . TXN ...Time: Min. Other: e -S i vim. i e - -2_5.4v., g a2- .?.. tr - lea ay , c l) e,l, IFC C nv l RS SB PRE : i 6.-- Min (Patient Tolerance) 1-10 8 20 80- 122�%LGo20 10-10 10-50 USP USC Mui @ Watts / CM 2 20/5% 40/10% 60/15% 80/20% 100/25% ----- HOT /HOT COLD I S Min Skin Condition : re -No ..-Nd al / 1 Today's Treatment: Well Tolerated GT> N POST TX VAS ❑ Case Management Towards Resolution / Stability ."' � ' d4 i RED FLAG: Yes No The patient's current complaint, past medical history, prior s p-4. i' 11 g y history, social history and review of systems are all well outlined i is medical record and these were reviewed today. New TX Plan " ont. TX Plan Modify TX Plan: End TX Plan Re-eval.Date: 15F�P t'_ 4 til it ❑ Anticipated Treatment Plan: Days Weeks /Visit # " of . PRN ❑ New Exercise Program Min. (See handout): _ ❑ Nutritional Support .. '" ■ Home.Instructions: • Taping / Strapping: • Min Type of Tape Used: Body Region • DME / Supports / Appliances: ❑ Studies: Rationale: ❑ Refer for outside services: Rationale: ❑ All exam information entered in ASHN tx. plan (See ASHN form) Highmark tx. plan (See HM form) ❑ Other: Consulted with the patient on the following: b' emove . " y s / Alter Ergonomics @ Work/ Home / Lifestyle Modification / Rest Y N / IHEP / Sleep Positions / Nutritional Counseling eaContrast/ RICE / Smoking Cessation Goals: 1 OAT Scores/Symptoms by 30 —50% by next evaluation/ Other: DIAGNOSI` S• 1,1- '- Add: . Omit: Today's Notes Daily Dictated Note Discharge Dictated OAT Highmark / ASHN TX &Progress Note ACN form Signature: —-- D.C. Ed Bartakovits 'ODavid Carbo DC 0 Mary Colman DC 0 Scott Colman DC 0 Timothy Duke DC 0 Paul Hetrick DC Edward Hevne C 0 Charlene Hobble DC 0 Ashley Viele DC o 1,,,, iPECIAL NOTATION: • The Hetrick Centers 1300 Bent Creek Boulevard Mechanicsburg, PA 17050 717-796-2225 CHIROPRACTOR SOAP NOTE 20 North Barbara Street Mount Joy, PA 17552 717-492-0303 •,. d: 25-1 ,' 0289 500 North Union Street Middletown, PA 17057 717-944-2225 DATE: friAl 5 Sir Thomas Court Suite 11A, Harrisburg, PA 17109 717-652-4002 =simian faillak ., Last Name:, - a First Name: "‘,... $ : D.O.B: IMI110 _ . S: Recurrent Acute Sub -acute Exacerbation Chronic New conjplaint Wellness DATE OF ONSET: L afli., cLc co. -4- ' Alt-e-tli- P12:*1 oris,- e -,-,o PQ ; ok Co c4.."4., S "ii f-C-Lee.4,. A01- VAS Pain Scale 1 2 34J6 7 89 10 See DT. 0: Ft. ..4-.4. 4, V'se & .1 0 Le 13/l 7;11,, t 4 " . -/6 ÷•3 e.e.... --, 2-17,.. , I.A...Ft kt,F, Eiv--1 ) LIZ C` •• 110.-e— w.,.... .7f..4.4 + 2 -17 . ack... aa....44...-- . . See DT. Osseous Findings & Osseous Treatment (Manipulation) C 0 1 2 3 4 (13)§ 04310.1Mik T 1 a) 3 CO 5 6(Do ' 8 46) 11 12 L 1 2 3 4 C.0 PR LB SR L •B BP Extraspinal: % T TH V FSE P) ANT D TH A ............E.I13 V V V G 4:1Z D la) A FSEP G SOT D TH A FSEP G D TH A F S E P H D TH A Soft Tissue Findings & Mon -Osseous Treatment : Tenderness/16,3 4 C T L EXTR / Tonicity 1(114 5 crD S-A / ' S -M : / S -P LS SCM 410) / T -M / T -L E (a) an )3 SP FR TP R SA T -MA / T -MI SUB SS IS P -MA / P -MI W -F / W -E (R / L) E TP ( 1 2) P SP FR LP ' Q1, LD P G —MAX / G—MED / G ---MIN TFL B TN Q GAS PF ( R7 L) E TP ( 1 2 ) P SP FR OTHER: ' E TP ( 1 2) P SP FR 1/A AIR MIR DMM PNF Time: MM. Manual Crjs- TXN Time: (Z:a MM. • Other. Car RS SB PRE : 1S— Mm (Patient Tolerance) 1-10 - 2 80-150 1-120 10-10 10-50 tIFC USP USC Mm Watts /CM 2 20/5% 40/10% 60/15% 80/20% 100/25% COLD I 6"--- Mm . Skin Condition : -Nortrl • t -Norm Today's Treatment: Well Tolerated. .Y N • POST TX VAS 0 Case Management Towards Resolution / Stability of Patient's Condition: , RED FLAG: Yes No The patient's current complaint, past medical history, prior surgeries", medications, allergies, family history, social history and review of systems are all well outfit> in tlioienta medical record and these were reviewed today. New TX Plan .a.at. TX Plan odify TX Plan: End TX Plan Re-eval.Date: I 0 Anticipated Treatment Plan: Days I Weeks / Visit # of PRN .... l__l New Exercise Program Min. (See handout) : RECORDS 0 Nutritional Support . 0 Home Instructions: SENT 0 Taping / Strapping: , Min Type of Tape Used: 13°K P•62i4112 012 0 DME / Supports! Appliances: ' 0• Studies: Rationale: 0 Refer for outside services: . Rationale: 0 All exam information entered in ASHN tx. plan (See ASHN form) Highmark tx. plan (See HM form) 0 Other: Consulted with the patient on the following: Limit/Remove Aggravatmg,Factors / Alter Ergonomics @ Work/ Home / Lifestyle Modification / Rest Y N / IHEP / Sleep Positions / Nutritional Counseling / ea ICE / Contrast! RICE / Smoking Cessation Goals: j. OAT Scores/Symptoms by 30 —50% by next evaluation/ Other: • DIAGNOSIS:/ •W: ' Add: •Omit: Today's Not , Dail ot4 ictated Note Discharge Dictated OAT Highmark / ASHN TX &Progress Note ACN form Signature: 0p Bartakovits 0 ' ODavid Carbo DC 0 Mary Colman DC 0 Scott Colman DC 0 Timothy Duke DC 0 Paul Hetrick DC [Edward Hey rDC 0 Charlene Hobble DC 0 Ashley Viele DC 6 tAA).... , It4 s 0 • SPECIAL NOTATION: The Hetrick Centers :1" OPRACTOR SOAP NOTE T • 25- 640289 1. DATE: A21- Last Name: 1300 Bent CreekiinideVaid-MeclianiCSInni PA 17050 717-796. 20 NorthEMbaia SiMit Monti:ICY, PA 17552 717492-0303 500/4h Llnicit'StreeeMiddletoWn, PA 17057 717-944-2225 445 Siiiii61714 EMii:slmiti; PA 17109. 717,652-4002 : • First Name: S: Recurrent Acute"Sub-cute Exacerbation Chronic New :complaint Wellness 1-4-5 • • 66 MI: DO.B: DATE OF ONSET: VAS Pain Scale 1 2 3n6 7 8 9 10 See DT. 0: )JG is •- ? i3 7- rp 1:fi.`e 71ft td st, eis See DT. Osseous Findin & Osseous Treatment (Mani ulation ' C 0 1®r 4 5 C331–Aft- T 1 d) 3 4 45) 6 7 8 9 10 11 L 1 2 3 4 sCP-erc P R L B SR L B BP Extraspinal: F S E Cfr_s_aljto V FSEP F S E p G F S P H CZ, T ANT D 0115 D SOT D DD TH A TH A TH A TH A TH A TH A Soft Tissue Findings & Non -Osseous Treattnent: Tendernasi/1 c:M4 C T L EXTR / Tonicity 1134 5 CP SO S-A / S -M S -P LS SCM / T -M / L) Eq." )zzt3 SP FR TP R SA T -MA / T-Ivq SUB 'SS IS ,p -MA 1? -MI W -F / W -E (R / L) E TP ( 1 2) P SP FR LP 6D LD P G —MAX / G --MED / G—MIN' TFL BTHQ GAS PF ( Rai E 1(?2)1 SP FR E TP ( 1 2) P SP FR OTHER IIA M/R DMM PNF Time' ' Min. Manual Time(E, Min. • • IFC RS SB PRE ' Min (Patient Talerance) 1441a 80-150 1420 10-10 10-50 USP USC ' Min; Watts /CM 2 20/5% 40/10% 60/15% 80/20% 100/25% COLD 1C"-- Min " Skin Condition : ormal Today's Treatment: WellTolerated . N. . • POST TX VAS • 0 Case Management Toiirdi Resolution iStabiliti of ritietit'S Condition: . RED FLAG: ,Yes No • The patient's current complaint, past medical hlitory prior stitgeries, mediCations, allergies, family history, social history and review of systems are all well outlined • ' t's Medical record and these were reviewed today. New TX Pian TX P n Modify TX Plan: '' • ' ' End TX Plan Re-eval.Date: -_,, El Anticipated Treatment Plan: , Days ' ' Weeks / Visit # of , PRN O New Exercise Program Min. (See handout).: El Nutritional Support ' 0 Home Instructions o Taping/ Strapping: ' 1: Min . 'type of Tape Used:. ,.- Body 1 At ;1 04-- DME / Supports / AppliaUces: - "'iTFAiii' L4 ji ,-1, ::: , A u LA.,• 0 Studies: :' ''. : ' ' : ' • ' ', '''' - Rationale: O Refer for outside services • ',.. ' • ' ' ': -,'.'' ..': . -- , 1 - . '. Rationale: 0 All exam information entered in ASHN tx plan (See ASHN fornz)'.Highmark tx.plan (See HM form) Consulted with the patisgon the following: Limit/Remove Aggmvating Factors / Alter Ergonomics @ Wcfrk/ Home / Lifestyle Modification / Rest Y NQI EIE.E.bSleep Positions / Nutritional Counseling / Heat/ ICE / Contrast/ RICE / Smoking Cessation ,, Goals: .1. OAT Scores/Symptoms by 30 –50% by next evaluation/ Other: Tat/ ( f - DIAGNOSIS. Today's Not Signature: Bartakovits ward Hevne Add: Omit: ctated Note..dbischarge Dictated OAT Highrnark / ASHN TX &Progress Note ACN form ODavid Carbo DC 0 MarY Colman DC d Scott Coln an DC 0 Timothy Duke DC 0 Pant Hetrick DC DC 0 Charleneillobbie DC 0 Ashley Viele DC SPECIAL NOTATION: The Hetrick Centers CHIROPRACTOR SOAP NO Ti x Ifl: 25-1640289 DATE: Last Name: 300 Bent Cr k Boulevard. Mecura, PA 17050 717-796 20 North Barbara S MountJoy, PA 17552 717-492-030 00 North Union S iddletown, PA 17057 717-944-2225 45 Sir Thomas Court Suite 11 S: Recurrent Acute /7Sub-acute Lslet Nflcr.� First Name: Fiarrisburg,.PA 17109 717-652-4002 MI:D.O.B: Exacerbation Chronic New complaint Wellness DATE OF ONSET: „{ 'T or..:s t e ► -: �a u E Pore. otic • VAS Paia Scale 1 2 3 4 b7 8 9 10 See DT. afar V.4+N( & J i' • vt mo rt F.1..lata , JUL �) w- -� t i ve. Le l4- ©: o ►y c - L4- 1 ld-O G _ `- 2,A .. Win :€ R,4-- 441%11/VSt • N41 F. See DT. 4, FlrtdrnEs &Osseous T. "potation C 0jt 3 4 <1 7 T 1 3 56 8 .9 10 11 .12 FSE' G� D A L 1 2 3 4a .9r. -,......G- �rj I). A PR L B ♦ F 'S E 'P ''' ' G SOT D TH A S R L B BP • F S:°E,. P.. .:...G D TH A Extraspinal: V F:;'S:'E:..P,;. H D TH A TH TH Soft Tissue Findings & Non -Osseous Treatment : Tenderness/1 4 C T I•- EXTR / Tdnicity. S SO S-A / S -M / S -P LS SCM T� / T -M (.. T -L 1 ) > E ) Q SP FR TP R SA ; TMA / T MI SUB SS IS P -MA / P-MIW-F" / W -E (R / L) . E - TP (1 2) P SP FR LP QL LD P G MAX / G—MED / G --MIN TFL B T: iH Q .:.G,AS PF (R / L) E TP .. (1 2) P SP FR OTHER: E TP (1 2) P SP FR 1/A A/R M/R DMM PNF Time: Min. . Manual a. .. TXN .Time: Min. do dovetna•. — M, Amonimemommirommoommi Other - SA, IFC CliS RS SB PRE : Min (Patient Tolerance) 1-10 80-12 1-120 10-10 10-50 ,USC Min Q Watts I CM 2 COLD ( $r Min Skin Condition: 20/5% 40110% 60/15% 80/20% 100/25% t=Norm Today's Treatment: Well Tolerated N O Case Management Towards Resolution I Stability of Patient's Condition: RED FLAG: Yes No The patient's "current complaint, past medical history, prior surgeries; medications allergies; family history; social history and review of systems are all well outlined in "y, 's medical record and these were reviewed today. New TX Plan ant. TX P1 Modify TX Plan: End TX Plan Re-eval.Date: 0 Anticipated Treatment Plan: Days Weeks / Visit # of PRN ❑ New Exercise Program _ Min. (See handout): O Nutritional Support: 0 Home Instructions: O Taping'/ Strapping: Min Type of Tape Used: O DME / Supports / Appliances: ❑ Studies: Rationale: ,E3 r-for outside services: C Yb1 P? - %1,r,c..t s 01. .. Rationale: 1Z o All exam information entered in ASHN tx. plan (Se ASHN form) Highmark plan"(S - ", form ❑ Other: l%47 Consulted with the patient on the following..411MM emov Modification I Rest Y : N / THEP I Sleep Positions / Nutritional Counseling/ He Goals: I OAT Scores/Symptoms by 301-50% by next evaluation/ Other: i Alter Ergonomics @ Work/ Home / Lifestyle E Contrast/ RICE / Smoking Cessation DIAGNOSIS/ Today's Notes: Signature: Add: .. Omit: Dictated Note Discharge Dictated OAT Highmark / ASHN TX &Progress Note ACN form D.C. 0 ' Bartako ❑David Carbo DC 0 Mary. Colman DC 0 Scott Coffman, DC 0 Timothy Duke DC 0 Paul Hetrick DC ward Hevnei DC ❑ Charlene Hobbie DC 0 Ashley Viele DC . ' PECIAL NOTATION: The Hetrick Centers CHIROPRACTOR SOAP NOTE Tax d: 25-1640289 DATE: Ii 7/.3– Creek Boulevard icsb PA 17050 717-796-2225 20 North Barbara Street Mount Joy, PA 17552 717-492-0303 500 North Union Street Middletown, PA 17057 717-944-2225 845 Sir Thomas Court Suite HA, Harrisburg, PA 17109 717-652-4002 Last Name: First Name: D.O.B: S: Recurrent Acu Sub-acuti Exacerbation Chronic New complaint Wellness D OF ONSET: 1/1 es Le th F u IALLI 4-- L2IitJ c4pp < de. 0: 5 ; IPN, - L 47 • 0 C 0 1 2 3 4 (0 7 T 1 a> 3 k 5 6 +CD 8 9 10 11 L 1 2 3 4 (,) P R L B SR L B BP Extraspinal: ; ft– 7v---, VAS Pain Scale 1 2 3 4 5 6 7 8 9 10 See DT. UAiiaj La. 4,). kA? .? •-.0 1 . SC- ah210 - 7. 1- a t rh See DT. TH A D TH A IrS,Ect,0 D<E) A F .S E P G SOT D TH A FSEP. D TH A F E P H D TH A Soft Tissue Findings & Non -Osseous Treatment : Tenderness/K2)3 ,4 C T L EXTR I Tonicity 4 SO S-A / S -M / S -P LS SCM / T -M T -L (1421) E,(&) 4D2 ) Q$ SP FR. TP R SA T -MA / T -MI SUB SS IS P44A /P-1\ till W -P / W -E (R / L) E TP ( 1 2) P SP FR LP QL LD P G —MAX / G—MED / G—M1N TFL T H Q GAS PF ( R / E TP ( 1 2) P SP FR OTHER: 1/A A/R DMM PNF Time: ; • ! Min. Manual E. TP ( 1 2) P SP FR TXN Time: Cit) MM. Other: IFC RS SB PRE : 5-7 Min (Patient Tolerance) 1-10 80-120 80-150 1-120 10-10 10-50 USP USC Min @ Warts/CM 2 20/5% 40/10% 60/15% 80/20% 100/25% COLD Min Skin Condition Today's Treatment: Well Tolerated N POST TX VAS O Case Management Towards Resolution / Stabilitynf Patient's Condition: RED FLAG: Yes No The patient's current complaint, past medical history, prior stirgeriis, medications; allergies, family history, social history and review of systems are all well outlined in the patient's medical record and these were reviewed today. New TX Plan <out. T)(11b Modify TX PlOn: End O Anticipated Treatment Plan: Days ! Weeks!'Visit # of O New Exercise Program ! Min. (See handout)3 Rase creo8 202 • . O Nutritional Support: 0 "Home Instructions: O Taping / Strapping: Mhi Type of Tape Used: Body Region O DME / Supports / Appliances: O Studies: ! Rationale: 414it O Refer for outside services:' : Rationale: O All exam information entered in ASHN tx. plan (See ASHArforrn) Highmark tx. plan (See HM form) 0 Other: Consulted with the patient on the following: Limit/Remove Aggravati Modification / Rest Y N / IHEP / Sleep Positions / Nutritional Counseling/ H Goals: I, OAT Scores/Symptoms by 30 –50% by next evaluation/ Other: er Ergonomics @ World Home / Lifestyle / Contrast/ RICE / Smoking Cessation DIAGNOSI S Add: Omit: Today's Not ailN Dictated Note Discharge Dictated OAT Highmark / ASHN TX &Progress Note ACN form Signature: 0 d Bartakovits ODavid Carbo DC 0 May Colman DC 0 Scott Colman DC 0 Timothy Duke DC 0 Paul Hetrick DC ward He DC 0 Charlene Hobbie DC 0 Ashley Viele DC . D.C. d> DR Bush PiNNACLEHFALTH M TRISTAN RADiOLOG' 5.PC1ALISTS Fax:717-561-8388 Oct 28 201d 02:27pm P002 240 Grandview Avenue Camp Hill, PA 17011 P: (717) 214-3330 F: (717) 214-3350 High Field MRI • Open MRI • PET Imaging • Computed Tomography (CT) • Digital Mammography • Ultrasound Bone Dehsltometry • X Ray / Fluoroscopy • Minimally Invasive Biopsy • Nuclear Medicine Account # 770165110 PATIENT NAME LOPER-GLAZER, LESLIE (DOB 03/07/1980) DATE OF SERVICE 10/08/2012 Patient ID: 800218115 Accession #: 770165110 AGEISEX 32/ Female CODE: 72141 EXAM: MM C SPINE HISTORY: Neck pain into both arms. Numbness and tingling in both hands. Decreased range of motion. Prior MVA. IMPRESSION: 1. Mild leftward scoliosis 2. No significant abnormality otherwise. FINDINGS: Multiplanar imaging was performed through the cervical spine without contrast, Motion artifact limits detail. Comparison is made to outside x-rays from September 6, 2012. There is a mild leftward scoliotic curvature with mild straightening of the cervical lordosis. There is no subluxation. There is no fracture. There is no focal disc herniation or stenosis. The cord signal is normal. The posterior fossa structures are unremarkable. ELECTRONICALLY SIGNED BRIAN P. BLOOM MD / BPB AT THE REQUEST OF Our other officeg: Harrisburg EDWARD HEVNER DC, DC Hershey 845 SIR THOMAS COURT Linglestown Road HARRISBURG PA 17109 Proud to be accredited by the American College of Radiology in CT, MR, US, Mammography, Stereotactic and Ultrasound -Guided Breast Biopsy, Breast MR, and by The Intersacietal Commission for Accreditation in NM, PET and Echocardiography. cc: Pace: 212. THE HETRICK CENTER You have a choice for Physical Therapy... choose us! 500 North Union Street 1300 Bent Creek Boulevard 20 North Barbara Street 845 Sir Thomas Court, Suite 11A Middletown, PA 17057 Mechanicsburg, PA 17050 Mount Joy, PA 17552 Harrisburg, PA 17109 Office: (717) 944-2225 Office: (717) 796-2225 Office: (717) 492-0303 Office: (717) 652-4002 Fax: (717) 944-0932 Fax: (717) 796-2229 Fax: (717) 492-0309 Fax: (717) 652-4005 October 25, 2012 Harrisburg RE: Leslie Glazer DOB: 7/19/80 PI CHIEF COMPLAINTS Ms. Glazer presents to the Hetrick Center of Harrisburg for re-evaluation of injuries sustained regarding a motor vehicle accident which occurred on 9/2/2012 in which he was a restrained passenger. Has been trying to do some exercises to maximize her improvement. She still complains of neck pain with intermittent headache activity and general back pain. She notes her neck pain today is a 5/10 in the Verbal Borg scale and worse in the lower back which was a 3/10 on the Verbal Borg scale. She notes that aggravating factors can be pulling up, sitting, reading, studying. She is a full time student. She is also working as a beautician, cutting hair, etc, which also tends to increase her neck and upper back pain. She also related the fact that she was rather asymptomatic prior to the motor vehicle accident, but she did have some history of neck pain and upper back 'pain. She has intermittent left upper extremity tingling, which has also improved with care. She did have an MRI dated 10/8/ 2012, please se report for findings. PAST MEDICAL HISTORY, PRIOR SURGERIES, MEDICATIONS, ALLERGIES, FAMILY HISTORY, SOCIAL HISTORY and REVIEW OF SYSTEMS The patient's past medical history, prior surgeries, medications, allergies, family history, social history, and a complete review of systems were done with the patient and pertinent positives and negatives are recorded in the paper chart and the rest in the HPI. PHYSICAL EXAMINATION Physical examination reveals a female Caucasian standing 5'2" tall, weighing approximately 130 pounds (self-reported weight and height). She is right handed. Cervicalrange of motion caused neck pain on flexion with a 25% loss, Left lateral flexion at 10%. Lumbar ROM revealed pain over the L5/superior left sacroiliac joint with Flexion and extension were reduced 20%. Jackson's compression remains positive on the left side for pain over the mid to upper thoracic spine. Patrick -Faber's was positive for mild increased lower back pain on the left side at 40 degrees. Continued to have multiple hypertonicities of the of the upper trapezius muscles, with the left being worse than the right, at a +2/3 and on the right a +1/2. Myotome strength of the upper extremities 5/5. Deep tendon reflexes were normal with a 2/5 of the upper and lower extremities. TREATMENT PLAN THE HETRICK CENTER Leslie Glazer October 25, 2012 Page 2 of 2 Patient will continue treatmentwith goals of maximum medical improvement, two times a week for two weeks. We will reevaluate her at that point to determine current status. It is my professional opinion beyond a reasonable degree of chiropractic certainty that the examination findings and the subjective complaints do continue to coincide with the motor vehicle accident that occurred on or about 09/02/2012. Further care is necessary and appropriate to treat said injuries and reduce symptoms. Goals: Increase ADL activity, increase C/L ROM, as well as reduce pain by 25%. Patient will follow up in approximately two days for additional treatment. Please Read: This questior ability to manage your every We realize that you may feel WHICH MOST CLOSELY D SEB OSWESTRY CHRONIC LOW BACK PAIN I ISABILITY QUESTIONNAIIE is designed to enable us to understand how much your low back pain has affected your activities. Please answer each section by circling the one choice that most applies to you. one statement may relate to you,. but PLEASE JUST CIRCLE THE ONE CHOICE YOUR PROBLEM RIGHT NOW. SECTIO 1 •— Pain Intensity The pain comes and goes and B. The pain is mild and does not C. The pain comes and goes is mo D. The pain is moderate and does E. The pain comes and goes and is F. The pain is severe and does no SECTION 2 — Personal Care I would not have to change my order to avoid pain. I do not normally change my though it causes some pain. 3. Washing and dressing increases change my way of doing it. Washing and dressing increases change my way of doing it. E. Because of the pain, I am unabl without help. Because of the pain, I am unabl without help. B. D. F. SECTION 3 — Lifting I can lift heavy weights with B. can lift heavy weights, but i c. Pain prevents me from lifting B. Pain prevents me from lifting but I can manage if they are c on a table. C. Pain prevents me from lifting age light to medium weights i timed. I can only lift very light wei mild. itch. vary much. vera. ary much. F. SECTION 4-Walkin^g Pain does not prevent m B. Pain prevents me from welkin C. Pain prevents me from D. Pain prevents me from welkin E. I can only walk while using a F. I am in bed most of the time SECTION 5 —Sitting. A I can sit in any chair as long I can only sit in my; favorite c Pain prevents me flout sitting D. Pain prevents me from sitting E. Pain prevents me from sitting F. Pain prevents me from sitting y of washing or dressing in of washing or dressing even e pain, but.I manage not to pain and I find it necessary to to do some washing and dressing do any washing or dressing eatlient's Signature e causes extra pain. heavy weights off the floor. eavy weights off the floor, nveniently positioned, e.g., eavy weights, but I can man- they are conveniently posi- at the most. g any distance. more than one mile. more than 1/2 mile. more than 04 mile. e or on crutches. d' have to craw➢ to the toilet. I like without pain. it as long as I like. ore than one hour. ore than I/2,hour. ore than ten minutes.. SECTION 6 — Sdiatrg can stand as long as I want without pain. have some pain while standing, but it does mit increase with time. cannot stand for longer than one hour without increasing pain. I cannot stand for longer than 1/2 hour without increasing pain. I cannot stand for longer than ten minutes without increasing pain. I avoid standing because it increases the pain straight away. D. F. SECTION 7 — Sleeping I get no pain in bed. B. I get pain in bed, but it does not prevent me from sleeping well. Because of pain, my normal night's sleep is reduced by less than i/, Because of pain, my normal night's sleep is reduced by less than t /: Because of pain, my normal night's sleep is reduced by less than 3P Pain prevents me from sleeping at all. SECTION S — Social Life My social life is normal and gives me no pain. My social life is normal, but increases the 'degree of my pain. Pain has no significant effect on my social life apart from limiting my more energetic interests, e.g., dancing, etc. D. Pain has restricted my social life and I do not go out very often. E. Pain has restricted my social life to my home. F. I have hardly any social life because of the pain. SECTION 9 —Traveling get no pain while traveling. get some pain while traveling, but none of my usual forms of travel make it any worse. I get extra pain while traveling, but it does not compel me to seek alternative forms of travel. D. I get extra pain while traveling, which compels me to seek alterna- 've forms of travel. E. Pain restricts all forms of travel. F. Pain prevents all forms of travel except that done lying down. SECTION 10 — Changing Degree of Pain y pain is rapidly getting better. y pain fluctuates, but overall is definitely getting better. C. My. pain seems to be getting better, but improvement is slow at present. D. ' My pain is neither getting better nor worse. F. My pairs is gradually worsening. F. My pain is rapidly worsening. C. Date Score: From: N. Hudson, K Tome -Nicholson, The Hetrick Center NECK PAIN IiISABILITY QUESTIONNAIRE Please Read: This questionnaire is designed to enable us to understand how much your neck pain has affected your ability to manage your everyday activities. Please answer each section by circling the one choice that most applies to you. We real- ize that you may feel that more than one statement may relate to you, but PLEASE JUST CIRCLE THE ONE CHOICE WHICH MOST CLOSELY DESCRIBES YOUR PROBLEM RIGHT NOW. SECTION 1 — Pain Intensity A. I have no pain at the moment. • , C. pain is very mild at the moment. The pain is moderate at the moment. D. The pain is fairly severe at the moment. E. The pain is very severe at the moment. F. The pain is the worst imaginable at the moment. SECTION 2 — Personal Care AJI can look after myself normally without causing extra pain. B. I can look after myself normally, but it causes extra pain. C. It is painful to look after myself and I am slow and careful. D. I need some help, but manage most'of my personal care: E. I need help everyday in most aspects of self-care. F. I do not get dressed, I wash with difficulty and stay in bed. SECTION 3 — Lifting I can lift heavy weights without extra pain. I can lift heavy weights, but'it causes, extra pain. C. Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positiohed,'e,g., on a table. D. Pain prevents me from lifting heavy weights off the floor, but I can manage light to medium weights if they are con- veniently positioned. I can lift very lightweights.' I cannot lift or carry anything at all. E. F. SECTION 4 —Reading I can read as much as I want to with no pain in my neck. I can read as much as I want to with slight pain in my neck. I can read as much as I want with moderate pain in my neck. C. E. F. SECTION 6 — Concentration A. B. E. F. I can concentrate fully when I want to with no difficulty. I can concentrate fully when I want to with slight difficulty. I have a fair degree of difficulty in concentrating when I want to. have a lot of difficulty in concentrating when I want to. I have a great deal of difficulty in concentrating when I want to. I cannot concentrate at all. SECTION 7 — Work can do as much work as I want to. can only do my usual work, but no more. . I can do most of my usual work, but no more. D. I cannot do my usual work. E: I can hardly do any work at all. F. I cannot do any work at all. SECTION 8 — Driving A. I can drive my car without any neck pain. an drive my car as long as I want with slight pain in my neck. drive my car as long as I want with moderate pain in my neck. D. I cannot drive my car as long as I want because of moderate pain in my neck. E. I can hardly drive at all because of severe pain in my neck. F. I cannot. drive my car at all. SECTION 9— Sleeping I cannot read as much as I want because of moderate pain in my neck. I cannot read as much as I want because of severe pain in my neck. I cannot read at all. SECTION 5 -Headaches A. B. (C) F. I have no headaches at all. I have slight headaches, which come infrequently. I have moderate headaches, which Come infrequently. I have moderate headaches, which come frequently. I have severe headaches, which come frequently. I have headaches almost all of the time. 3. F. I have no trouble sleeping. My sleep is slightly disturbed (less than 1 hour sleepless). My sleep is mildly disturbed (1-2 hours sleepless). My sleep is moderately disturbed (2-3 hours sleepless). My sleep is greatly disturbed (3-5 hours sleepless). My sleep is completely disturbed (5-7 hours sleepless). SECTION 10 — Recreation A. I am able to engage in all of my recreational activities, with no neck pain at all. I am able to engage in all of my recreational activities, with some pain in my neck. I am able to engage in most, but not all of my usual recreational activities because of pain in my neck. I am able to engage in a few of my usual recreational activities be- cause of pain'in my neck. I can hardly do any recreational activities because of pain in my neck. I cannot do any recreational activities at all. B. D. E. F. Patient's Signature Score: After Vernon & Mior, 1991 Reprinted by permission of the Journal of Manipulative and Physiological Therapeutics SPECIAL NOTATION: The Hetrick Centers CHIROPRACTOR SOAP NOTE Tax 1d:25- 640289 DATE: d AmiA '� �- -- Amw Last Name: S: Recurrent Acute 1300 Bent Creek Boulevard Mechanicsburg, PA 17050 717-796-2225 20 North Barbara Street Mount Joy, PA 17552 717-492-0303 500 North Union Street Middletown, PA 17057 717-944-2225 845 Sir Thomas Court Suite 11A, arrisburg, PA 17109 717-652-4002 First Name: MI: D.O.B: ub-acute Exacerbation Chronic New complaint Wellness DATE OF ONSET: VAS Pain Scale 1 2 3 4t }}6 7 8 9 10rr�D� See DT) Osseous Findings & Osseous Treatment (Manipulation) C T I CD 3 4'Z�6 6 9 10 11 12 L 1 2 3 QDG) PR L B SR L B BP .xtraspinal: V V FSE P FSE. P FSE P G H T ANT SOT D TH A D TH A D A D TH A D TH A D TH A Soft Tissue Findings & Non -Osseous Treatment : Tenderness/I Ca4 C T L EXTR / Tonicity M 5 0 SO S-A / S -M / S -P LS SCM T i- 1 / T -M / T -L ri E <lb (1 2) C SP FR TP R SA T -MA / T -MI, SUB SS IS P -MA / P -MI W -F / W -E (R / L) E TP (1 2) P P FR LP ()LD P G —MAX / G—MED / G—MIN TFL B T H Q . GAS PF (‹is E TP (1 2 P SP FR OTHER: E TP (1 2) SP FR I/A A/R M/R DMM PNF Time: Other: Min. Manual ``.) TXN Timer Min. IFC RS SB PRE : Min (Patient Tolerance) 1-10 80-120 0-15 1-120 10-10 10-50 USP USC Min @ Watts/ CM 2 20/5% 40/10% 60/15% 80/20% 100/25% COLD / S"-- Min Skin Condition . Today's Treatment: Well Tolerated N POST TX VAS ❑ Case Management Towards Resolution / Stability of Patient's Condition: RED FLAG: Yes No The patient's current complaint, past medical history, prior surgeries, medications, allergies, family history, social history and review of systems are all well outlined in the patient's medical record d these were reviewed today. New TX Plan Cont. TX Plan di TX Plan: End TX Plan Re-eval.Date: ❑ Anticipated Treatment Plan: Days a.3 Weeks / Visit # . .. , .. ,of PRN ❑ New Exercise Program — Min. (See handout): ❑ Nutritional Support: ° 0 Home Instructions: ❑ Taping / Strapping: Min Type of Tape Used: �)Qdy Region ❑ DME / Supports / Appliances: ❑ Studies: ❑ Refer for outside services: ❑ All exam information entered in ASHN tx. plan (See ASHN form) Highmark tx. plan (See HM form) ❑ Other: Consulted with the patient on the following: emove - ggravatin: Facto / Alter Ergonomics @ Work/ Home / Lifestyle Modification / Rest Y N / IHEP / Sleep Positions /Nutritional Counseling .+ - Contrast/ RICE / Smoking Cessation Goals: j OAT Scores/Symptoms by 30 –50% by next evaluation/ Other: Omit: DIAGNOSIS: S a W: �� Today's Notes • ,!i' Highmark / ASHN TX &Progress Discharge Dictated s Note ACN form Signature: D.C. 0 Ed Bartakovits DC avid Carbo DC 0 Mary Colman DC 0 Scott Colman DC 0 Timothy Duke DC 0 Paul Hetrick DC 1--I - „_Lke., r -sr, f1 e-t.te., r:et- no SPE L NOTATION: „., ......„ ..,. , , • . , _ „ .. . The Hetrick Centers , , , , . , . , 1300 Bent Creek Boulevard Mechanicsburg, PA 17050 717-796-2225 20 North Barbara Street Joy, PA 17552 717-492-0303 C III ' OPRACTOR SOAP NOTE Tax Id: 25-1640289 DATE: 10 .1. (,, '1 500 North Union Street Middletown, PA 17057 717-944-2225 845 Sir Thomas Court Suite 11A, Harrisburg, PA 17109 717-652-4002 Last Name: G la 7e. • First Name: I. -g i I ; t MI: D.O.B: 3, S: Recurrent Acute Sub -acute Exacerbation Chronic New complaint Weilness DAT OF ONSET: / 11ed c0 4. idi p - Rt.+ tw tid i IlY\rre‘lt.'1 't" "4- ex"; di. ( Piefr.41, 3 / 1 "" • VAS Pain Scale 1 2 30)5 67 89 10 See DT. _jot' l 41-- o 1..... yl,...-• J- O: R , . u L 7:,e 7.17 •P P 71;4•- r . F- _ . y... , . - e - , - A f /-d.. letvw. (a , L'i tenv., See DT. Osseous Findings & Osseous Treatment (Maui . u tion) C 0 1 2 3 4 (3) 6 a T 1 6 3 (rb 5 6 o 8 9 10 11 12 L 1 2 3 4 6,9 PR L B SR L B BP Extraspinal:. - F S E .7 TH V F S E ' C ANT D TH A v V V V E 4. <1Z5 D illitik A F $ E P G SOT D A FSEP G D TH A FSE P H D TH A ioft Tissue Findings & Non -Osseous Treatment : Tendernes 0 SO S-A / S -M / S -P LS SCM T -M / T -L da 4 C T L. EXTR / Tonicity E.)' Ctl 2 ) C111 SP FR 5 TP R SA T -MA / T -MI SUB SS IS P -MA / P -MI W -F / W -E (R / L E. TP ( 1 2) P SP FR LP (6)LD P --MAX / G—MED / 0—MIN TFL B T H Q GAS PF 4f E TP ( 1 2) C:b SP FR OTHER: E. TP ( 1 2) P SP FR I/A A/R M,R DMM PNF Time: Min. Manual TXN Time: Other: MM. IFC RS SB PRE : 16-- Min (Patient Tolerance) 1-10 80-l2'!1-120 10-10 10-50 USP USC Min @ Watts/CM 2 20/5% 40/10% 60/15% 80/20% 100/25% COLD 16' Min Skin Condition PrC7T'ke7--)inal Today's Treatment: Well Tolerated POST TX VAS Case Management Towards Resolution / Stability of Patient's Condition: RED FLAG: Yes No The patient's current complaint, past medical history, prior surgeries, medications; allergies, family history, social history and review of systems are all well outlined in the patient's medical record and these were reviewed today. New TX Plan Cnt. TX PramModify TX Plan: End TX Plan Re-eval.Date: E Anticipated Treatment Plan: Days Weeks / Visit # of PRN O New Exercise Program MM. (See handout): O Nutritional Support: 0 Home Instructions: O Taping / Strapping: MM Type of Tape Used: Body Region O DME / Supports / Appliances: O Studies: CORDS SENT Rationale: OCT 2 6 2012 O Refer for outside services: , Rationale: O All exam information entered in ASHN tx. plan (See ASHN form) Higlunark tx. plan (See HM form) 0 Other: Consulted with the patient on the following: Limit/Remove Aggravating Factors / Alter Ergonomics @ World Home / Lifestyle Modification / Rest Y N / IHEP / Sleep Positions / Nutritional Counseling / Heat/ ICE / Contrast/ RICE / Smoking Cessation Goals: jOAT Scores/Symptoms by 30-50% by next evaluation! Other: DIAGNOSIS: Today's Not Signature: Ed Bartakovit dward Hevn • Dail No Add: Omit: Dictated Note Discharge Dictated OAT Highmark / ASHN TX &Progress Note ACN form D.C. ODavid Carbo DC 0 Mary Colman DC 0 Scott Colman DC 0 Timothy Duke DC 0 Paul Hetrick DC DC 0 Charlene Hobbie DC 0 Ashley Viele DC SPECIAL NOTATION: The Hetrick Centers CHIROPRACTOR SOAP NOTE Tax d: 25- 0289 DATE: Yr. • — AU •I• 41111111=11111111111111W 1300 Bent Creek Boulevard Mechanicsburg, PA 17050 717-796-2225 20 North Barbara Street Mount Joy, PA 17552 717-492-0303 500 North Union Street Middletown, PA 17057 717-944-2225 5 Sir Thomas Court Suite 11A, Harrisburg, PA 17109 717-652 Last Name: S: Recurrent Acute Sub-acp Exacerbation Chronic Ne -.719 plAztutA. tiAA iln," -t. F -t( c • P -4-4k.. 44,- First Name: MI: D.O.B:: M1. complaint Wellness DATE OF ONSET: p4r, t Ltat 100 1€14..." -r. "711a VAS Pain Scale 1 2 3:2b5 6 7 8 9 10 See DT. Ai04.7/ t!) dti2J / Aft 1--F. t 70 - laktutc.t... 1p e, E 7-6.11 1- , cl .1 W. • /111- -t See DT. Osseous Findzns & Osseous Treatmentn* ulatio C 0 I 2 3 4 &1i 6C1) T 1 (5) 3 cf5 6 eb 8 9 10 11 12 L 1 2 3 4 e...V PR L B SR L B BP lExtraspinal: V P FSE P FSE P FSE P (&) T ANT G SOT D TH A A A • TI! A D TH A D TH A Soft Tissue Findings & Non -Osseous Treatment : Tenderness/I. 2 4 C T L EXTR / Tonicity (,J4 5 CP SO S-A / S -M / S -P LS SCM ' T -M / T- E (II) p 2) 'V SP FR , TP R SA T -MA / T -ML SUB SS IS P -MA / P -MI W -F / W -E (R / L) E TP ( 1 2) P SP FR LP QL LD P G —MAX / G—MED / G—MIN TFL B T H Q GAS PF ( R / L) E TP * ( 1 2) P SP FR OTHER E TP ( 1 2) P SP FR 1/A A/R M/R DMM PNF Time: Min. Manual (,) TXN Time: (L Min. Other C. -5p.i,,a --$-wl,,f_4,-,` 4 .i — 3 54( -0 / V , IFC RS SB PRE: Min (Patient Tolerance) 1- 80-150 1-120 10-10 10-50 USP USC Min @ Watts /CM 2 20/5% 40/10% 60/15% 80/20% 100/25% COLD Min Skin Condition No / Today's Treatment: Well TolerateRY) N POST TX VAS O Case Management Towards Resolution / Stability of Patient's Condition: RED FLAG: Yes No The patient'S current complaint, past medical history, prior stirgeries, medication; allergies, family history, social history and review of systems are all well outlined • • ' gedical record and these were reviewed today. New TX Plan . _ odify TX Plan: End TX Plan Re-eval.Date: O Anticipated Treatment Plan: V-- Days Z Weeks / Visit # of ,PRN a...New Exercise Program MM. (See handout): O Nutritional Support: 0 Home Instructions: O Taping/ Strapping: i Min Type of Tape Used: O DME / Supports / Appliances: COR4eNT O Studies: Rationale: O Refer for outside services: ,NOV 01 2012 Rationale: O All exam information entered in ASHN ix. plan (See ASHN form) Highmark tx. plan (See HM form) 0 Other: Consulted with ti patient on the following: emove Modification eN / IHEP I Sleep Positions lNutrttional Counsel Contrast/ RICE! Smoking Cessation Goals: J, OAT Scores/Symptoms by 30 —50% by next evaluation/ Other: / Alter Ergonomics @ Work/ Home / Lifestyle DIAGNOS Today's Not Add: Omit: Dictated Note Discharge Dictated OAT Highmark / ASHN TX &Progress Note ACN form Signature: D.C. d Bartakovits David Carbo DC 0 Mary Colman DC 0 Scott Colman DC 0 Timothy Duke DC 0 Paul Hetrick DC ward He er DC 0 Charlene Hobbie DC 0 Ashley Viele DC SPECIAL NOTATION: The Hetrick Centers CHIROPRACTOR SOAP NOTE Tax Id: 25-1640289 DATE: 11 5; i7, - Last Name: G (� er S: Recurrent Acute l-esI,- P Sub -acute . �ty 1300 Bent Creek Boulevard Mechanicsburg, PA 17050 717-796-222 20 North Barbara Street Mount Joy, PA 17552 717492.0303 00 North Union Street Middletown, PA 17057 717-944-2225 845 Sir Thomas Court Suite 11A, Harrisburg, PA 17109 717-652-4002 First Name:. .p. D.O.B: Exacerbation Chronic New complaint Wellness DATE Off ONSET: u• VAS Pain Scale 12304)56789 10 S DT. 0: See DT. Osseous Findin Osseous Trea ent (Mani ulation) C 0 1 2 3 4_ T 1®3 4 6 L 1 2 3 4 P R L B S R L B BP Extraspinal: 7 8 9 10 11 12 V V V .E.,T FSE ei ANT 3Ca) G FSE P G SOT FSE P G F:S `E . P H D TH A D TH A D 1 A D TH A D TH A D TH A Soft Tissue Findings & Non -Osseous Treatment : Tenderness/1 2F3 4.0 T L.. EXTR / Tonicity 1 )4 5 SO S-A / S -M / S -P LS SCM / T -M /. T -L® L) E ( 2) (ESP FR TP SA T -MA / T -MI SUB SS IS P -MA / P -MI W -F / W -E (R / E. TP (1 2) P SP FR LP D P G —MAX / G—MED / G—M1N TFL BTHQ GAS PF < ' t) E (f.,P0 (1 2) P SP FR OTHER E; TP 1 2) P SP FR UA A/R M R DMM PNF Time: Min. Manual TXN Ti Min. Other. IFC USP HV RS SB PRE: Min (Patient Tolerance) I -i 120. 0-150 I-120 10-10 10-50 USC Min @ Watts / CM 2 20/5% 40/10% 60/15% 80/20% 100/25% COLD 1 S Min Skin Condition : Today's Treatment: Well Tolerat 0 Case Management Towards Resolution / Stability of Patient's Conditio E The patient's current complaint, past medical history, prior surgeries, medications, allergies, ami are all well outlined i medical record and these were reviewed today. New TX Plan Cont. TX Pla Modify TX Plan: Ellie.* 06 g g-eval.Date: ❑ Anticipated Treatment Plan: Days Weeks / Visit # of PRN ❑ New Exercise Program _ Min. (See handout): al ,4�ErNareview of systems No ❑ Nutritional Support: 0 Home Instructions: ❑ Taping / Strapping: Miro Type of Tape Used: Body Region ❑ DME / Supports / Appliances: 0 Studies: Rationale: ❑ Refer for outside services: Rationale: ❑ All exam information entered in ASHN tx. plan (See ASHN form) Higlunark tx. plan (See HM form) ❑ Other: Consulted with the patient on the following: Limit/Remove Aggravating Modification / Rest Y N / IHEP / Sleep Positions / Nutritional Counseling/ He Goals: j OAT Scores/Symptoms by 30 —50% by next evaluation/ Other. / Alter Ergonomics @ World Home / Lifestyle ontrast/ RICE / Smoking Cessation DIAGNOS .. • •.r...i Add: Omit: today's Notes. oily Dictated Note Discharge Dictated OAT Highmark / ASHN TX &Progress Note ACN form Signature: C D.C. O id Bartakovi : a C ❑David Carbo DC 0 Mary Colman DC 0 Scott Colman DC 0 Timothy Duke DC 0 Paul Hetrick DC ,Edward ner DC 0 Charlene Hobble DC 0 Ashley Viele DC SPECIAL NOTATION: The Hetrick Centers CHIROP CTOR SOAP NOTE T. d: 2 -1640289 DATE: 1300 Bent CreekBemlevarriMechanicsburg, PA 17050 7114 5 20 North Barbara Street Mount Joy, PA 17552 717-492-0303 ' 500 North Union Street Middletown, PA 17057 717-994-2225 845 Sir Thomas Court Suite IA, Barri .urg, PA 17109 717-652-4002 First Name: D.O.B: Exacerbation Chronic 1,ewcompl t Wellness OF ONS -Sao,/ a 11/4/1 7 Ac.,_ 1"0,...e e—, '9k VAS Pain Scale 1 2 341...3 67 89 10 See DT. 0: 4/1 a—?i /07. ce Atli 75 flA4fii 14 7,' . See DT. Osseous Findings & Osseous Treatment (Manipulation) C 0 1 2 3 4 T 1 M 3 6) 5 7 8 9 10 11 12 L 1 2 3 4 aN PR L B SR L B BP Extraspinal: 6 1.0 T D TH ANT D. TH SOT D TH D TH D TH A A A Soft Tissue Findings & Non -Osseous Tr atment : Tendern 4 C.T L EXTR Tonicity 4 5 CP SO S-A / S -M / S -P LS, SCM. T -M / T- 2 ) SP FR TP R SA T -MA / T -MI SUB. SS IS ,P -MA / 0 -MI W -F t W -E (R / L) E TP ( 1 2 ) P SP FR LP QL LD P , G —MAX / G—MED / G—MIN TFL B TH Q . GAS PF ( R / L) E TP ( 1 2 ) P SP FR OTHER: E TP ( 1 2) P SP FR 1/A A/R M/R DMM PNF Time: Min. Manual <___TXN, Ti Other. IFC RS SB PRE: i .§-'-- Min (Patient Tolerance) 1-1 0-150 1-120 10-10 10-50 US? USC Min @ Watts / CM 2 20/5% 40/10% 6O/15% 80/20% 100/25% COLD /5 -Min Skin Condition:/ Pc7Tt7tionna---17).L__ Today's Treatment: Well Tolerated POST TX VAS Case Management Towards Resolution / Stability of Patient's Condition: RED FLAG: Yes No The patient's current complaint, past medical history, prior surgeries, medications, allergies, family history, social history and review of systems are all well outlined i 'ent's medical record and these were reviewed today. New TX Plan Modify TX Plan: nd TX Plan 0 Anticipated Treatment Plan: Days Weeks / Visit # PRN 0 New Exercise Program Min. (See handout): O Nutritional Support: 0 Home Instructions: O Taping / StraPping: Min Type of Tape Used: O DME / Supports / Appliances: O Studies: Rationale: r, O Refer for outside services: Rationa 0 All exam information entered in ASHN tx. plan (See ASHN form) Highmark tx. plan (See HM form) 0 Other: Re-eval.Date: ody .B Consulted with the patient on the following: Limit/Remove Aggra atin Factors / Alter Ergonomics @ Work/ Home / Lifestyle Modification / Rest Y N / IHEP / Sleep Positions I Nutritional Counseling 41 ICE / Contrast/ RICE / Smoking Cessation Goals: OAT Scores/Symptoms by 30 —50% by next evaluation! Other: DIAGNOS Today's Notes: Dictated Note Discharge Dictated OAT Highmark / ASHN TX &Progress Note ACN form Signature: D.C. Odd Bartakovits David Carbo DC 0 Mary Colman DC 0 Scott Colman DC 0 Timothy Duke DC 0 Paul Hetrick DC Prlwarrl rtr fl AAL.., Add: Omit: SPECIAL NOTATION: The Hetrick Centers CHIROPRACTOR SOAP NOTE Tax • : 25- ' 640289 DATE: I 1300 Bent Creek Boulevard Mechamcsburg, PA 17050 717-796-2225 20 North Barbara Street Mount Joy, PA 17552 7 7-4 -0303 500 North Union Street Middletown, PA 17057 717-944-2225 845 Sir Thomas Court Suite I1A,Hanisburg, PA 17109 717-652-4002 worm Last Name: \ zit& ir..,_ A First Name:. MI: D.O.B. M. S: Recurrent Acute Sub -acute Exace o Chronic New complaintWolin ss DATE OF ONSET: A),..,.....4 U (2,,,E.., .c“...r. ---, •ot . ' VAS Pain Scale 1 2 3 6 7 : 9 10 See DT. 0: S ' • i IV 7 / - nm +-' itur-00.11--Amiu" aumnisi1 See DT. Osseous Findin . & Osseous Treatment (Maui. ul do ) C 0 1 2 3 4 69(6) 7 , T 1 OD 3 CP ,(' 7 8 9 10 11 12 L 1 2 3 P R L B S R L B BP. Extraspinal: , '. TH -.......1:E_ V (la ANT D • A T -7-3)E a!) 0 CO) D ' A V V V F.$ E P G SOT D TH A F S E P G D TH A F. S .E P H D TH A Soft Tissue Findings & Non-OSseous Treatment : Tenderness/0..13 4 C T EXTR / Tonicity CP SO S-A / :/. S -P LS SCM .(Zb / T -M t T -L E (15-‘‘ 2) (y SP FR TP R SA T -MA / T -Ml ,SUB SS IS P -MA / W -F / (R / L) E TP ( 1 2) P SP FR LP QL LD P G —MAX / 0—MED / G—MIN TFL BTHQ GAS PF ( R / L) E TP ( 1 2) P SP FR OTHER: E, TP ( 1 2) P SP FR MIR DMM PNF Time:' MM. Manual TXN Time) Min. 5 VA A/R Other: • IFC •4Eb RS SB •PRE I ..------- •Min (Patient Tolerance) 1-180-150 1-120 10-10 10-50 USP USC Min ® Watts / CM 2 20/5% 40/10% 60/15% 80/20% 100/25% COLD f.S-----Min Skin Condition Today's Treatthenii'Well Tolera N POST TX VAS _1 Case Management Tovvards Resolution / Stability of Patient's Condition: 0 0 RED FLAG: Yes No The patient's current complaint;, past medical history, prior surgeries, medications, allergies, family history, social history and review of systems are all well outlined ' 's medical record and these were reviewed today. New TX Plan •Modify TX Plan: Anticipated Treatment PimDays Weeks / Min. (See handout): New Exercise Program. Nutritional Support: End TX Plan Re-eval.Date: Visit # of PRN 0 'Home Instructions: Taping / Strapping: • ' Min Type of Tape Used: DME / Supports / Appliances: RECORDS SENT Body Region ' NOV i2ZO17_, Studies: Rationale: Refer for outside services: , Rationale: All exam information entered in ASHN tx. plan (See ASHN form) Highmark tx. plan (See HM form) Other: Consulted with the patient on thelfollowin Modification / Rest Y N/ IHEP / Slee0 Positions / Nutritional Counseling/ He Goals: j OAT Score/Symptoms by 30'--50% by next evaluation! Other: DIAGNOSIS: Today's Not Ergono Con R CE Smoking Cessation Add: Omit: -0 Note Discharge Dictated OAT Highmark / ASHN TX &Progress Note ACN form Signature: D.C. 0 d Bartakovits D David Garbo 13C 0 Mary Colman DC, 0 Scott Colman DC 0 Timothy Duke DC 0 Paul Hetrick DC Edward Hevn C 0 Charlene Hobbie DC 0 Ashley Viele DC THE HETRICK CENTER You have a choke for Physical Therapy...c hoose us! 500 North Union Street 1300 Bent Creek Boulevard 20 North Barbara Street 845 Sir Thomas Court, Suite 11A Middletown, PA 17057 Mechanicsburg, PA 17050 Mount Joy, PA 17552 Harrisburg, PA 17109 Office: (717) 944-2225 Office: (717) 796-2225 Office: (717) 492-0303 Office: (717) 652-4002 Fax: (717) 944-0932 Fax: (717) 796-2229 Fax: (717) 492-0309 Fax: (717) 652-4005 November 16, 2012 Harrisburg RE: Leslie Glazer DOB: 03/07/1980 PERSONAL INJURY CLINICAL HISTORY Ms. Glazer is a 32 -year-old Caucasian female who stands 5'2" and weighing 130 pounds. She is right-handed. She was involved in a motor vehicle accident with her husband on 09/02/12 for which she sustained injuries to her neck predominantly and upper back and secondarily into the lower back. She notes that her lower back pain has progressed well with only limited stiffness remaining at this time. Neck pain fluctuates but she notes today that her pain scale is a 6/10 on a Verbal Borg Scale. She has fluctuating levels of headache activity noting she has a recent headache including today x two days with computer work and reading. She notes since the accident she is more sensitive to reading, computer work and holding her head in a flexed position. This tends to aggravate her neck pain and does tend to spike her headache activity. She has had more stress recently with increased school work and work with her normal job. She notes that her average pain over the last week is a 4-5/10. She has been taking Vicodin on occasion for headache activity which has given her some relief. She denies any traumas, etc., which are contributing to her current complaint. PHYSICAL EXAMINATION Cervical range of motion is restricted with bilateral rotation with a 20% loss and moderate stiffness and pain noted throughout the C-spine. Left lateral flexion was decreased 10% with pain noted in the same areas. Lumbar and thoracic ranges of motion were restricted with flexion with a 20% loss. More pain noted in the mid to upper back. Extension with a 20% loss and pain in the same areas and bilateral lateral flexion was decreased 10% with mid back pain noted over the thoracic and lumbar junction. Orthopedic testing is positive for pain reproduction with maximum cervical compression with pain noted over the upper cervical area at the C1-C2 level. Bilateral Jackson's compression reproduced only mild pain in the mid to lower portion of the C-spine. She denies any upper extremity pain or paresthesia with this test although she does have periods of tingly sensation in the left upper extremity. Cervical herniated disc has been ruled out with an MM dated 10/08/12. Please see this report from Tristan Associates. The impression is mild left scoliosis. No other significant abnormality was noted. She does have a straightening of the normal cervical lordosis. Chiropractic palpatory findings reveal vertebral subluxation complex/vertebral fixation as noted in her SOAP note. Elevated muscle tonicity at the trapezius muscles bilaterally with multiple THE HETRICK CENTER Leslie Glazer Page 2 of 2 November 16, 2012 trigger points noted. More tenderness and increased muscle tone in the right trapezius versus the left. She also has some muscle rigidity over the suboccipital muscles; left worse than right. Edema formation around the posterior elements of C5 and C7 as well as T4 and T7. TREATMENT PLAN The patient was treated today with high volt Galvanic stimulation and heat, manual traction to the cervical spine, passive stretching to the paraspinals of the C-spine and the appropriate specific adjustments to fixation levels. Patient continues to respond favorably to care but additional treatment is medically indicated for further pain reduction and to reach a point of maximum medical improvement or preinjury status. Patient will be seen over the next two weeks x two visits and again re-evaluated to determine her current status at that time. She is stretching at home with isometric resistance in the cervical spine and stretching to the paraspinals in the C- spine as instructed in the office. I do hold the same diagnosis. The prognosis remains favorable. The patient will follow-up in approximately three days for additional treatment. It is my professional opinion within a reasonable degree of chiropractic certainty that the subjective complaints put forth by the patient and my examination findings do continue to coincide with the automobile accident which occurred on 09/02/]%l. Further care is medically appropriate and necessary. Please also see the ADL forms for di iculties and aggravating factors revolving her activities of daily living. Edward L/Hevner, D.C. ELH/h2 SPECIAL NOTATION: The Hetrick Centers CHIROPRACTOR SOAP NOTE Tax le: 25- ' 64028 DATE: , 1300 Bent Creek Boulevard Mechanicsbu :,PA 17050 7 7- 6-2225 20 North Baibara Street Mount Joy, PA 17552 717-492-0303 • 500 North Union Street iddletown, PA 17057 117-944-2225 845 Sir Thomas Court Suite 11 ., Harrisburg, PA 17109 717-6 2 02 mama Mk Last Name: es.. ..!..A First Name: , D.O. 4, IF _ . S: Recurrent Acute Sub -acute Exacerbation Chronic New complaint Wellness DATE _ OF ONSET:. . - VAS Pain Scale 2 3 4 5 6 7 9 10 : . . . . See D Osseous Findings &Osseous Treatment (Manipulation) C 0 1 (5) 3 40 .6. , < D T 1 67) 3 (g) 5 6(J) 8 9 10 11 12 L I 2 3 4 5 PR L B SR L B BP Extraspinal: V F S E P T D TH F S E ' - ANT D TH A V V V V. FSEP G F/D D TH A F SEP G SOT 0 TH A FSEPG 0 TH A F S E P H D TH A Soft Tissue Findings & Non -Osseous Treatment : Tenderness/k)1 C T L EXTR / TOnicity 15 CP SO S-A / S -M 1 . / S -P LS SCM ' e -al.) / T -M / T -L - E5a) 02) SP FR TP R SA T -MA / T -MI SUB SS IS .P -MA / P -MI W -F 7 W -E (R / L) E TP ( 1 2) P SP FR LP QL LD P G —MAX / G—MED / G—MIN TFL B T H Q , GAS PF ( R. / L) E TP • ( 1 2) P SP FR OTHER: E. TP ( 1 2) P SP FR l/A A/R M/R DMM PNF Time: . Min. Manual IMF Time: in. • Other: . 1FC (2:0 RS SB PRE : I S Mm (Patient Tolerance) I-1 80-120 80-150 1120 10-10 10-50 - USP USC MM @ ' Watts/CM 2 .40/5% 40/10% 6015% 80/20% 100/25% .t:Do COLD t .S.-- MM Skin Conditiota.1/ ost-Norm . Today's Treatment: Well Tolerated CD N . POST TX VAS 0 Case Management Towards Resolution / Stability of Patient's Condition: RED FLAG: Yes No The patient's current complaint, past medical history, prior surgeries, medications, allergies, family history, social history and review of systems are all well outlined in the patient's medical record and these were reviewed today. New TX Plan Cont. TX PlanoctglifTPrTX an: End TX Plan Re-eval.Date: 0 Anticipated Treatment Plan: 6, Days R,. Weeks / Visit # of PRN 0 New Exercise Program - MM. (See handout):• RECORDS 0 Nutritional Support: SENT 0 Home Instructions: , 0 Taping / Strapping: i Min Type of Tape Used: . Body Regi 0 DME / Supports / Appliances: . 0 Studies: . Rationale: 0 Refer for outside services: ' - Rationale: 0 All exam information entered in ASHN tx. plan (See ASHN form) Highmark tx. plan (See HM form) 0 Other: Consulted with the patient on the following:h(r-Taemov- , • ...Ax; atin Fa o E o o... (..%) ome /Lifestyle Modification / Rest Y N / IHEP / Sleep Positions / Nutritional Counseling I li TJi Contrast! RICE / Smoking Cessation Goals: 1 OAT Scores/Symptoms by 30 —50% by next evaluation/ Other. . - DIAGNOSIS: - , Add: Omit: Today's Notes: • • • Dic Note Discharge Dictated OAT Highmark / ASHN TX &Progress Note ACN form ....., §ignature: D.C. .0 Ed Bartakovi D ilDavid Carbo DC 0 Mary Colman DC 0 Scott Colman DC 0 Timothy Duke DC 0 Paul Hetrick DC Edward evn DC U chariene.t-t000ie SPECIAL NOTATION: The Hetrick Centers CHIROPRACTOR SOAP NOTE Tax Id: 25-1640289 - DATE: I i, 496 • / 7- 1300 Bent Creek Boulevard Mechanicsburg, PA 17050 717-796-2225 20 North Barbara Street Mown Joy, PA 17552 717-492-0303 500 North Union Street Midilletown, PA 17057 717-944-2225 845 Sir Thomas Court Suite 11A, Harrisburg, PA 17109 717-6524002 Last Name: GI QZ.Of . First Name: Le s MI: D.O.B: 3, 9- • V) S: Recurrent Acute Sub -acute Exacerbation Chronic New complaint • Wellness DATE OF ONSET: 1.—Q -S114 eta 1"0.1 ...tact" -I-L./ay. 5.4 IAIZJ 6 fly-v1s41., ",c -i. 1- z. i,+ 5 i eit .1.- vt.44 A- ,+ ei,y1,4.-}„,.at . kj. iti, `,. • 70% y i 2 /4 Ve lAt 1-- a I A- n\e-Ji. lAcv..-4 a iie..1,./ VAS Piiii Scale 1 2367 89 10 See DT. : S - . . . 1 v--/ , i?.11T51 o, -c. -2_, rL(, 17 ) 4— 3-- 74,, --a_....._ See DT. Osseous Findin & Osseous Treatment (Mani,. illation) C 0 (1) A 3 4 d.) 6 7 T 1 2 dp 4 5 (6-) 7 8 9 10 11 12 L I 2 3 4 0 P R. L B SR L B BP .Extraspinal: CIEnnitto A V V V 'T D TH A F ' , 6., D TH A CP D TH A FSEP 0 SI D A FSEP .G D TH A F.'S .E P H D TH A Soft Tissue Findings & Non -Osteous Treatment : Tendernes0:13 .4 C T L EXTR T�nici 45 CP 1 -1 -S --A / S -M ./, S -P LS SCIVI <jai/ T -M /. T -L• (132 ) c:13 SP FR TP R SA T -MA / T -MI SUB SS IS P -MA / P -MI W -F / W -E (R / L) E TP ( 1 2) P SP FR LP QL LD P G —MAX / 0—MED / G—MIN TFL B .T.H Q. GAS PF ( R / L) ,E TP ( 1 2) P SP FR OTHER: E TP ( 1 2) P SP FR TXN Time: (k) Min. Mi VA A/R MIR DMM PNF Time: n. Manual Other: • IFC USP •Ce - USC COLD RS SB PRE : 1,6 min (Patient Tolerance) 1-10 80-120 -120 10-10 10-50 Watts / CM 2 20/5% 40/10% 60/15% 80/20% 100/25% Skin Condition: Today's Treatment: Well Tolerated a) N : ,: POST TX VAS O Case Management Towards Resolution / Stability of Patient's Condition: RED FLAG: Yes No The patient's current complaint; past medical history, prior surgeries, medications, allergies, family history, social history and review of systems are all well outlined ' nt, edical record and these were reviewed today. New TX Plan Cont. TX Plan Modify TX Plan: End TX Plan Re-eval.Date: - O Anticipated Treatment PTan: Days Weeks / Visit # of - PRN E] New Exercise Program Min. (See handout): ' , 0 Nutritional Support: - 0 Home Instructions: ' •00-' ,Y :1 Taping / Strapping: Min Type of Tape Used: .. , Body Region . 1, -:.:3 0 DME / Supports / Appliances: El Studies: Rationale: -..-.) ,—; , O Refer for outside services: Rationale: O All exam information entered in ASHN tx. plan (See ASHN form) Highmark tx. plan (See HM form El Other: Consulted with the patient on the following: Limit/Remove Aggravatin F Alter Ergonomics @ Work/ Home I Lifestyle Modification / Rest Y N / 'NEP / SleeR Positions / Nutritional Counseling/ W Contrast/ RICE / Smoking Cessation Goals: j OAT Score/Symptoms by 30'-50% by next evaluation/ Other: DIAGNOSI Toda3N No es: Signature: Add: Omit: Dictated Note Discharge Dictated OAT Highmark / ASHN TX &Progress Note ACN form D.C. Edward Bartakovi C ElDavid Carbo DC 0 Mary Colman DC 0 Scott Colman DC 0 Timothy Duke DC 0 Paul Hetrick DC Edward He er DC 0 Charlene Hobbie DC 0 Ashley Viele DC • • ......_ ..._ ...._ . The Hetrick Centers _ 1300 Creek BOulevard Mechanisbutg, PA 17050 717-796-2225 CHIROPRACTOR SOAP NOTE 20 NorthBarbara Street Mount Joy, PA 17552 717-492-0303 Tax • • 25- 640289 500 North Union Street Middletown, PA 17057 717-944-2225 , DATE: e)7°' 845 Sir Timm* Court Suite 11A, ' b A 17109 717-652-4002 , Last Name: First Name: MI: D.O.B: 5/7/P S: RecurrentAcute Sub cute Exacerbatio Chronic New complaint Wellness DATE OF ONSET: 0 " if t A • , 1 ..2_ - , 11-43., 1,,,iuLtfi-,,, s4yki 4- 4_ ( .640,14 /4. L// 7L4( l' 03,, AS Pain Scale 1 23 45 67 89 1 See DT. : (Ix 1 -75,_„0 < +- 7-- 11. C •gorvs-- uF cJ-63 I.. /0701. go -7. 0 ..., -4_ i - 5 , / t-- ,,,I,`- - 4 A.,/ See DT. Osseous Findings & Osseous Treatment (Manipulation) C 0 1 dj 3 4 6) 6 7 _.,. T 1 Co 3 4 (5) 6 7 8C. g". 11 Ca 11 12 L 1 2 3 4 CE) PR L B SR L B BP EXtraSpinal: , F S E 2b T D TH A CV v ‘' V F S E T D TH A E 0 4 -, D 4ztl A F S E G SOT D TH A F S E P G P TH A FSEP H D TH A Soft Tissue Findings & Non -Osseous Treatment : Tendtrness/1 4 C T L EXTR / Tonieit53 45 SO S-A / S -M . / S -P LS SCM <a) / T -M / T- MAW E <ID (...12 ) 4' SP FR TP _.11, SA T -MA / T -MI SUB SS IS P -MA / P -MI W -F / W -E (R / E TP ( 1 2) ' P SP FR LP4iii. ..)_ LD P G —MAX / G—MED / G—MIN TFL B T H Q GAS PF QJ E ' ( 1 2) P SP FR OTHER: ( 1 2) P SP FR I/A A/R. M/R DMM PNF Time: Min. Manual TXN Time:C.15 Min. 11- t Other C-- —7S rai-12.4-v;/../ MI nahp.e- 2._ .01.-e - lo p ,.... . ...I IFC CrV) RS SB PRE : / 5---- Min (Patient Tolerance) 1 80-120 0 150 1-120 10-10 10-50 11 tn% . USP USC Min ® Watts/CM 2 20/5% 40/10% 60/15% 80/20% 100/25% 0: la COLD 1 S—Min Skin Condition: ottre-Norni-a-1!) &ii"Norm Today's Treatment: Well TolerateddD N POST TX VAS • 0 Case Management Towards Resolution / Stability Of Patient's Condition: RED FLAG: Yes No The patient's current complaint, past medical history, prior surgeries, medications, allergies, family history, social history and review of systems are all well outlined in the patient's medical record and these were reviewed today. New TX Plan Cont. TX Plan Modify TX Plan: End TX Plan Re-eval.Date: 0 Anticipated Treatment Plan: Days Weeks / Visit # of PRN 0 New Exercise Program Min. (See handout): 0 Nutritional Support: 0 Horne Instructions: eCel' 0 Taping / Strapping:. : *n Type of Tape Used: 114494egion 0 DME / Supports / Appliances: . *Ok 0 Studies: • Rationale: SCA, ' F 0 Refer for outside services: • Rationale: 0 El All exam information entered in ASHN tx. plan (See ASHN form) Highmark tx. plan (See form) 0 Other: Consulted with the pati on the following: Limit/Remove Aggravat0Factors / Alter Ergonomics @ Work/ Home / Lifestyle Modification / Rest Y N Sleep Positions / Nutritional Counseling "in. — ICE / Contrast/ RICE / Smoking Cessation Uoals: 1 OAT Scores/Sympto u s by 30 -50% by next evaluation/ Other: DIAGNOSIS: WrYli-D, ' , Add: " Omit: - 7-a 1 -, Today's Not I.: 0 ' Dictated Note Discharge Dictated OAT Highmark / ASHN TX &Progress Note ACN form Signature: ----7--...,_.- D.C. 51Ed Bartakovits Dr 0David Carbo DC D Mary Colman DC 0 Scott Colman DC 0 Timothy Duke DC 0 Paul Hetrick DC ward evneCharlene HoDOe SPECIAL NOTATION: The Hetrick Centers C}LLROPRACTOR SOAP NOTE Tax 54; 25-1640289 DATE: 1300 Bent Creek Boulevard Mechanicsburg, PA 17050 717-796-222 20 North Barbara Street Mount Joy, PA 17552 717-492-0303 500 North Union Street Middletown, PA 17057 717-944-2225 845 Sir Thomas Court Suite11A, Harrisburg, PA, 17109 717-6524002 ast Name: S: Recurrent Acute Le., 1 First Name: Sub-aiute Exacerbation Chronic New R c 4.437141X D.O.B: implaint Wellness DATE OF ONSET: 0%4 td.47 r VAS Pain Scale 1 2 3 4 5 6 7 8 9 10 See DT. ) See DT. 0° sseoes FindinsOsseous Treatment ant ulatio c0 T L 1 2 P R S R Extraspinal: 4 an 7 6 CI 8 9 10 11 FSE F S B BP L Lir cl- E P G F S F F..S :E TH D TH A D CiP A D TH A D TH A TH A Soft Tissue Findings & Non -Osseous Treatment: Tenderness/k$ 4 C T L EXTR Tonicity 1aa3 45 CP SO S-A / S -M / S -P LS SCM <II / T -M / T -L Ectj2 )Z SP FR. TP R SA T -MA / T -MI SUB SS IS P -MA / P -MI W -F / W -E (R / L) E TP ( 1 2) P SP FR LP QL LD P G —MAX / G—MED / G—MIN TFL BT H Q GAS PF ( R / L) E TP ( 1 2) P SP FR OTHER: E TP ( 1 2) P SP FR VA A/R MR DMM PNF Time: Min. Manual Other: TXN Time: Min. IFC CZ) RS SB PRE: USP USC Min @ COLD js' Min Min (Patient Tolerance) 1-1 80-12 Watts / CM 2 20/5% 46/10% 60/15% 80-150 1-120 10-10 10-50 80120% 100/25% . Skin Condition : re -No Today's Treatment: Well Tolerated 0 OD Case Management Towards Resolution / Stability of Patient's Condition: POST TX VAS D FLAG: Yes No The patient's current complaint, past medical' history, prior surgeries, medications, allergies, family history; social history and review of systems are all well outlined in the •' t's medical record and these were reviewed today. New TX Plan ont. TX Plan odify TX Plan: Anticipated TreatMent Plan: Days Weeks / Visit # New ExerciseProgram Min. (See handout): Nutritional Support: 0 Home Instructions: Taping / Strapping: ' Min Type of Tape Used: ody Re DME / Supports / Appliances: Studies: Rationale: 4.? Refer for outside services: Rationale: All exam information entered in ASHN tx. plan (See ASHN form) Highmark tx. plan (See HM form) Other: End TX Plan PRN Re-eval.Date: Consulted witt. e patient on the followingCaltaemove Modification / st N / IHEP / Sleep Positions / Nutritional Counselin Goals: j OAT Scorei/Symptoms by 30 –50% by next evaluation/ Other: Alter Ergonomics @ Work/ Home / Lifestyle Contrast/ RICE / Smoking Cessation DIAGNOSIS Today's Nt Add: Omit: Dictated Note Discharge Dictated OAT Highmark / ASHN TX &Progress Note ACN form Signature: D.C. EEd Bartakovi C 'David Carbo DC 0 MaryColman DC 0 Scott Colman DC 0 Timothy Duke DC 0 Paul Hetrick DC Edward Hev/er DC 0 Charlene Hobbie DC 0 Ashley Viele DC • 0 SPECIAL NOTATION: The Hetrick Centers CHIROPRACTOR SOAP NOTE Tax Id:. 25-1640289 DATE: 1300 Bent Creek Boulevard burg,PA47 717-796-2 20 North Barbara Street.Mount Joy, PA 17552 717-492-0303 500 North Union Street Middletown, PA 17057 717•944-2225 845 Sir Thomas Court Suite.11A, Harrisburg, PA 17109 717-652-4002 Name: First Name: / S: Recurrent Acute u cute Exacerbation Chronic complaint Welin 4. I 1LA 4L L' 4 y 4- ..1'fIVP ill"0 ir Be 414 0 MI: D.O.B: VAS DATE OF ONSET: ain Scale 1 2 3 4 5 6 7 8 9 10 See DT. 0: 1/ s ij,Lj% See DT. Osseous Findings & Osseous Treatment (Manipulation) C 02 3 4 6) 6 5c6) 7 8 9 10 11 12 L 1 2 3 4 Cb. PR L B SR L B BP. Extraspinal: T D TH A ANT D. TH A D A F S E P G SOT D TH A F S E P G D TH A F S E P H 13 TEl A Soft Tissue Findings & Non -Osseous Treatment : Tenderness/ a 3 4 C T I EXTR Tonicity il(D4 S CD SO S-A / S -M S -P LS SCM / T -M / T -L iiV1 E (rp) (D2) ()SP FR TP R SA T -MA / T -MI SUB SS IS P -MA / P -MI W -F / W -E : (R / L) E: TP ( 1 2) P SP FR LP QL LD P G —MAX I 0—MED / G—MIN TFL B T H Q GAS PF ( R / L) B TP ( 1 2) P SP FR OTHER: •B TP ( 1 2 ) P SP FR UA A/R. M/R DMM PNF Min. Manual TXN Time:() MM. Other: IFC () RS SB • PRE : . Min (Patient Tolerance) 1-10 80-120 80-150 1-120 10-10 10-50 USP USC Mm @ Watts / di12 20/5% 40/10% 60/15% 80/20% 100/25% COLD Sidn Condition Today's Treatment: Well Tolerated POST TX VAS Case Management Towards Resolution I Stability Of PatleaOs Condition : RED FLAG: Yes No The patient's current complaint, past medical history, prior surgeries ; medications, allergies, family history, social history and review of systems are all well outlin ' '. t's medical record and these were reviewed today. New TX Plan n Modify TX Plan: End TX Plan Re-eval.Date: Anticipated Treatment Plan: Days Weeks I Visit # of PRN New Exercise Program . MM. (See handout): Nutritional Support : 0 Home InstrubtiotRECrtr, WI D g 0 Taping / Strapping: i Min Type of Tape Used: S ion O DME / Supports / Appliances: O Studies: Rationale: EC 0 3 20 12 O Refer for outside services: Rationale: O All exam information entered in ASIIN Ix. plan (See ASHN form) Highmark tx. plan (See HM form) O Other: Consulted with the patient on, the following; Limit/Remove Aggravating F M ors / Alter Ergonomics @ Work/ Home / Lifestyle Modification / Rest Y N / IHEP / Sleep Positions I Nutritional Counseling / He Contrast/ RICE / Smoking Cessation Goals: 4. OAT Scores/Symptoms by 30 -so% by next evaluation/ Other: DIAGNOSIS: Today's Notes: Gignature: 0 d Bartakovits 0David Carbo DC 0 Mary Colman DC 0 Scott Colman DC 0 Timothy Duke DC 0 Paul Hetrick DC 1JJdward Hevn DC 0 Charlene Hobbie DC 0 Ashley Viele DC Add: Omit: Dictated Note Discharge Dictated OAT. Highmark / ASH N TX &Progress Note ACN form 500 North Union Street Middletown, PA 17057 Office: (717) 944-2225 Fax: (717) 944-0932 December 6, 2012 Harrisburg RE: DOB: PI THE HETRICK CENTER You have a choice for Physical Therapy...c hoose us! 1300 Bent Creek Boulevard Mechanicsburg, PA 17050 Office: (717) 796-2225 Fax: (717) 796-2229 Leslie Glazer 03/07/1980 CLINICAL HISTORY 20 North Barbara Street Mount Joy, PA 17552 Office: (717) 492-0303 Fax: (717) 492-0309 845 Sir Thomas Court, Suite 1 1A Harrisburg, PA 17109 Office: (717) 652-4002 Fax: (717) 652-4005 Ms. Glazer has been under our care since September 5, 2012 for injuries she sustained in a motor vehicle accident on 9/2/2012 for which she was a restrained passenger. She did receive injuries to her neck, upper back and to a lesser degree to her lower back following this accident. She has been doing well with some mild temporary setbacks to the neck and upper back pain secondary to increased study time, stress and repetitive motion which occurs while performing her job duties as a hair stylist. She rates her neck pain as a 5/10 on the pain scale, and the lower back is a 2/10. PAST MEDICAL HISTORY, PRIOR SURGERIES, MEDICATIONS, ALLERGIES, FAMILY HISTORY, SOCIAL HISTORY and REVIEW OF SYSTEMS The patient's past medical history, prior surgeries, medications, family history, social history, and a complete review of systems was done with the patient and pertinent positives and negatives are recorded in the paper chart and the rest in the HPI. PHYSICAL EXAMINATION: Cervical range of motion was restricted and caused general neck pain, of left lateral flexion with a 10% loss, flexion with a 20% loss, extension with a 10% loss, left rotation with a 25% loss and right rotation with a 5% loss. She continues to have pain with Jackson's compression bilaterally, which increases mid to lower power neck pain. She notes the quality of pain is a quick, sharp shooting pain which does not persist. Palpation of the bilateral carotids was normal. She has continued elevated muscle tonicity of the left trapezius muscle with a +2 and on the right trapezius with a +1 to 2. She has mild increased pain with isometric resistance to bilateral rotation in the mid to lower portion of the c -spine. Myotomes in the upper extremities are within normal limits. Deep tendon reflexes in the upper extremities are within normal limits. Chiropractic palpatory findings reveal fixations/vertebral subluxations as noted in further detail in the SOAP note. She also has elevated muscle tonicity of the suboccipital muscles, predominantly on the left side. She gets a varied degree of headache activity. She notes having one to two moderate headaches per week, typically surrounding intense reading or studying. She has been taking Vicodin as needed which gives her relief and allows her to sleep. Without medication she notes having some sleep difficulty at the time. THE HETRICK CENTER Leslie Glazer Page 2 of 2 December 6, 2012 CLINICAL FINDINGS: The patient does continue to progress towards maximum medical improvement with a slower than expected response in the neck/upper back due to the aggravating factors previously discussed. It is my chiropractic, professional opinion that the subjective complaints put forth by the patient and my exam findings do continue to coincide with the automobile accident which occurred on 9/2/2012. Further care is appropriate and medically necessary to reach maximum medical improvement or a pre -accident status, whichever comes first. TREATMENT PLAN The patient will be seen for the next two weeks, two times per week, to follow up with her complaints and determine current status. She has been compliant with her home exercise program. She is also icing and she ha's increased her water intake. The patient will follow up in approximately three days for additional treatment. Please see previous dictations and intake for further details regarding the automobile accident and the patient's injuries. Prognosis remains good. I hold the same diagnosis. Further goals consist of further pain reduction of a 2-3/10 in the neck and 0-1 in the l• back upon next reevaluation, and increased range of motion plus 25% vs. what we tested to ' We discussed signs, symptoms and sequelea of a worsening situation. dward EL Hevner, D.C. NECK PAIN DISABILITY QUESTIONNAIRE The Hetrick Center Please Read: This questionnaire is designed to enable us to understand how much your neck pain has affected your ability to manage your everyday activities. Please answer each section by circling the one choice that most applies to you. We real- ize that you may feel that more than one statement may relate to you, but PLEASE JUST CIRCLE THE ONE CHOICE WHICH MOST CLOSELY DESCRIBES YOUR PROBLEM RIGHT NOW. SECTION 1 — Pain Intensity A. I have no pain at the moment. The pain is very mild at the moment. The pain is moderate at the moment. D. The pain is fairly severe at the moment. E. The pain is very severe at the moment. F. The pain is the worst imaginable at the moment. SECTION 2 — Personal Care can look after myself normally without causing extra pain can look after myself normally, but it causes extra pain. C. It is painful to look after myself and I am slow and careful. D.I need some help, but 'manage 'inost of my personal care. I need help every day in most aspects of self-care. P. I do not get dressed, I wash with difficulty and stay in bed., SECTION 3 —Lifting I can lift heavy weights without extra pain. can lift heavy weights, but it causes extra pain. Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned, -e.g., on a table. S. D. Pain prevents me from lifting heavy weights off the floor, but I can manage light to medium weights if they are con- veniently positioned. I can lift very light weights. I cannot lift or carry anything at all. E. F. SECTION 4 —Reading I can read as much as I want to with no pain in my neck. B. I can read as much as I want to with slight pain in my nec C. I can read as much as I want, with.imoderate pain in my. eck. D. cannot read as much as I want because of moderate pain in my neck. I cannot read as much as I want because of severe pain in my neck. E. F. I cannot read at all. SECTION 5 —Headaches f,4 A. I have no headaches at all. B. I have slight headaches, which come infrequently. C. I have moderate headaches, which come infrequently. ) I have moderate headaches, which come frequently. B. I have severe headaches, which come frequently. F. I have headaches almost all of the time. 'atient's Signa SECTION 6— Concentration A. I can concentrate fully when I want to with no difficulty. I can concentrate fully when I want to with slight difficulty. 1 have a fair degree of difficulty in concentrating when I want to. I have a lot of difficulty in concentrating when I want to. I have a great deal of difficulty in concentrating when I want to. I cannot concentrate at all. D. E. F. SECTION 7— Work 1 can do as much work as I want to. I can only do my usual work, but no more. C. I can do most of my usual work, but no more. D. I cannot do my usual work. . I can hardly do any work at all. F. I cannot do any work at all. SECTION 8— Driving A. I can drive my car without any neck pain. can drive my car as long as I want with slight pain in my neck. can drive my car as long as I want with moderate pain in my neck. . I cannot drive my car as long as I want because of moderate pain in my neck. E. I can hardly drive at all because of severe pain in my neck. F. I cannot drive my car at all. SECTION 9— Sleeping A. I have no trouble sleeping. My sleep is slightly disturbed (less than 1 hour sleepless). My sleep is mildly disturbed (1-2 hours sleepless). My sleep is moderately disturbed (2-3 hours sleepless). My sleep is greatly disturbed (3-5 hours sleepless). ▪ My sleep is completely disturbed (5-7 hours sleepless). SECTION 10 — Recreation A. I am able to engage in all of my recreational activities, with no neck pain at all. B. I am able to engage in all of my recreational activities, with some pain in my neck. I am able to engage in most, but not all of my usual recreational activities because of pain in my neck. D. I am able to engage in a' few of my usual recreational activities be- cause of pain in my neck. E. I can hardly do any recreational activities because of pain in my neck. F. I cannot do any recreational activities at all. Date PACO Score: After Vernon & Mior, 1991 Reprinted by permission of the Journal of Manipulative and Physiological Therapeutics 4444 S The Hetrick Center VISED OSWESTRY CHRONIC LOW BACK IS MI'TT QUESTIONNAIRE Please Read: This questionnaire is designed to enable us to understand how much your Iow back pain has affected your ability to manage your everyactivities. Please answer each sec on by circling the one choice that most applies to you. We realize that you may feel tht more than one statement may relate to you, but PLEASE JUST CIRCLE THE ONE CHOICE I83fN WHICH MOST CLOSELY D ,y 'RIEESYOI31LPROl3ZEM GHT OW ....,_ ...,............. ..............., ._.... ,._ ...,........:..... _........... _. .......... .......:.... , ....., .. ,........,......_..................... CTION 1— Pain Intensity A. The pain comes and goes and is B. The pain is mild and does not C. The pain comes and goes is mo D. The pain is moderate and does E. The pain comes and goes and is F. The pain is severe and does not SECTION 2 — Personal Care � would not have to change my order to avoid pain. I do not normally change my w though it causes some pain. 3. Washing and dressing increases change my way of doing it. Washing and dressing increas change my way of doing it. Because of the pain, I am un without help. Because of the pain, I sin unabl without help. D. E. F. Very mild. ry much. te. ,ary much. vere. ary much. y of washing or dressing in of washing or dressing even pain, but I manage not to pain and I find it necessary to do some washing and dressing to do any washing or dressing SECTION 3 — Lifting A. I can lift heavy weights with . t extra pain. B. can lift heavy weights, but i causes extra paw. . Pain prevents me from lifting heavy weighty off the floor. D. Pain prevents me from lifting eavy weights off the floor, but I can manage if they are c « aveniently positioned, e.g., on a table. Pain prevents me from lifting 1i eavy weights, but I can in age light to medium weights i they are conveniently posi- tioned. I can only lift very light wei, at the most. F. CTION 4 —Walking A. Pain does not prevent me fro B. Pain prevents me from walkin C. Pain prevents me from welkin D. Pain prevents me from w E. I can only walk while using a F. I am in bed most of the time C. D. E. F. TION 5 —Sitting can sit in any chair as long I can only sit in my favorite c Pain prevents me from sitting Pain prevents me from sitting Pain prevents me from sitting Pain prevents me from ' w Patient's Signature walking any distance. more than one mile. more than 1/2 mile. ore than 1/4 mile. or on crutches. d have to crawl to e toilet. I like without pain. air as long as I like. ore than one hour. ore than I/2 hour. re than ten minutes. all. SECTION 6 — Standing A. I can stand as long as I want without pain. have some pain while standing, but it does not increase with time cannot stand for longer than one hour without increasing pain. I cannot stand for longer than 1/2 hour without increasing pain. I cannot stand for longer than ten minutes without increasing pain. F. I avoid standing because it increases the pain straight away. SECTION 7 — Sleeping D. A. D. F. I get no pain in bed. get pain in bed, but it does not prevent me from sleeping well. ecause of pain, my normal night's sleep is reduced by less than i Because of pain, my normal night's sleep is reduced by less than Because of pain, my normal night's sleep is reduced by less than 3r Pain prevents me front sleeping at all. C. D. E. F. ON g — Social Life y social life is normal and gives me no pain. y social life is normal, but increases the degree of my pain. Pain has no significant effect on my social life apart from limiting my more energetic interests, e.g., dancing, etc. Pain has restricted my social life and I do not go out very often. Pain has restricted my social life to my home. I have hardly any social life because of the pain. SECTION 9 — Traveling o pain while traveling. some pain while traveling, but none of my usual forms of vel make it any worse. I get extra pain while traveling, but it does not compel me to seek alternative forms of travel. D. I get extra pain while traveling, which compels me to seek alterna- tive forms of travel. Pain restricts all forms of traveL Pain prevents all forms of travel except that done lying down. SECTION 1©— Changing Degree of Pain y pain is rapidly getting better. y pain fluctuates, but overall is definitely getting better. My pain seems to be getting better, but improvement is slow at present. D. My pain is neither getting better nor worse. E. My pain is gradually worsening. F. My pain is rapidly worsening. C. E. F. Score: From: N. Hudson, K. Tome -Nicholson, A. Brazen; 14$9 Co SPECIAL NOTATION: The Hetrick Centers - 1300 Bent Creek Bot1evard Mechanicsburg, PA 17050 7 7-7962225 CHIROPRACTOR SOAP NOTE . . .. , 20 North Barbara Street Mount Joy, PA 17552 717-492-0303 Tax Id: 25-1640289 500,North Union Street Middletown, PA 17057 717-944-2225 :; DATE: /77 .V-- 45 Sir Thomas Court Harrisburg,PA 17109 Suite 11A, 717-652-4002 Last Name: First Name: MI: ! D.O.B: 3 6Pij S: Recurrent Acute Sub -acute Exacerbation Chronic New complaint Wellness DATE OF ONSET: VAS Pain Scale 1 3 4 6 189 Osseous Fin 'n!s & OsseousTreatmeat (Mani , ulation) ' ' • ' ' C 0 12 3 4 6)S) 7 • T 1 co 3 c 5 6 7 8 9 10 11 12 L 1 2 3 4 .1) PR L B S R L 13 BP Extraspinal: TH 4.-- V V F ANT 'D TH - /D D TH A F.;$ E P D TH A PSE P D TH A F:S IE P 11 D TH A Soft Tissue Findings & Non -Osseous Treatnieut : Tenderness3ACTL EXTR / Tonicity 123 45 CP SO S-A / S -M / .S -P LS SCM CM/ T -M qDL) E ( 1 2 ) <ESP FR TP R SA T -MA T -MI SUB SS ' IS P -MA / P -MI • W -F W -E (R / L) E. TP ( 1 2) P SP FR LP QL LD P 0 —MAX / G—MED / G—MIN TFL W T H Q GAS PF ( R / L) E TP ( 1 2) P SP FR OTHER: E • TP ( 1 2) P SP FR TXN Time: Min, IFC RS RS SB PRE: 5 Min (Patient Tolerance) 1-1 0-150 1-120 10-10 10-50 USP USC Min Watts/CM2 20/5% 40/10% 60/15% 80/20% 100125% COLD Min Skirt Condition . IIA A/R M,R DMM PNF Time: Other: . Min. Manual Today's Treatment: Well Tolerate t 0 Case Management Towards' Resolution / Stability of Patient's Condition: are all well outlined in the patient's medical record and these were reviewed today. New TX Plan (nt. TiPlati)Modify TX Plan: End TX Plan Re-eval.Date: Anticipated Treatment Plan: .1...... Days . g... Weeks / Visit # of PRN New Exercise Program Min. (See handout): rS) Nutritional Support: . 0 Home Instructions: DODODOO 00 RED FLAG: Yes No The patient's Current complaint, Past medical history, priorsurgeries, medications; allergies, family history; social history and review of systems Taping / Strapping: ' Min Type f TaPe Used: DME / Supports / Appliances: Studies: Rationale: Refer for outside services: Rationale: All exam information entered in ASHN bc. plan (See ASHN form) Highmark tx. plan (See HM form) Other: Consulted with the patient on the foilowing: Limit/Remove Factors/AlterAggrava...Ergonomics @ World Home / Lifestyle Modification / Rest Y N / MEP / Sleep Positions / Nutritional Counseling NW/ ICE/ Contrast/ RICE / Smoking Cessation Goals: 1. OAT Scores/Symptoms b 30 ;40% by next evaluation/ Other: DIAGNOSIS: Today's Note Signature: tctatedNo e Discharge Dictated OAT Highmaric / ASHN TX &Progress Note ACN form D.C. o Ed Bartakovits DC Edward Hevner D avid Carbo DC .0 Mary Colman DC 0 Scott Colman DC 0 Timothy Duke DC 0 Paul Hetrick DC 0 Charlene Hobble DC 0 Ashley Viele DC DR Bush 2012-12-17 11:04 The Hetrick Center d0 • Fax:717-561-8388 Oct 28 201t1 02:28pm P008/018 17176524005 » 7175618388 P 2/2 The Hetrick Center You Have A Choice for Your Physical Therapy...Chaos@ Us, December 12, 2012 RE: Leslie Glazer DOB: 03-07-1980 Dear Dr. Bush: Ms. Glazer has been under our care for injuries sustained in a MVA on 9-2-2012. She presented to our office on 9-6-2012 complaining of neck, upper back, and lower back and left sided, intermittent upper extremity paresthesia. We did secure a c -spine MRI to rule - out HNP/DDD. The results revealed to disc involvement. On her latest re-evaluation she has progressed well in her lower back complaints. Neck, upper back and left sided upper extremity symptoms do persist, but with reductions in pain intensity and frequency. I will continue treatment at 2x week for 4 weeks. Se will be re-evaluated at that time to determine her current status and need for additional care. Our continued goals of treatment are further pain reduction, increase c -ROM and reduce upper extremity pain. If you require any additional information please contact at your earliest convenience, Best Regards, Edward L. Hevner, D.C. www hclrickccntrrcaey S00 Noah Union Street Middletown, PA 17057 Office; 717.944?225 faexloHl e: 717.944.0932 1300 Rem Crack Bou/e' 1 Mechanicsburg PA 17050 Office; 717.796.2225 Pacrimik: 717.796.2229 • 20 North Barbara Street MounrJoy. PA 17552 Office:: 717,493.0303 Fu simllc: 717.492.0309 845 Sir Thomas Cl., Ste. 11A Harrisburg, PA 17109 Office: 717.652,4002 .Facsimile. 717.65' 4005 SPECIAL NOTATION: The Hetrick Centers CIBROPRACTOR SOAP NOTE Tax Id. 25-1 0289 , 0289 PATE: ,,,,,P-.,, 1300 Bent Creek Boulevard Mechamcsburg PA 17050 717-79 -2225 20 North B hera Street MountJoy, PA 17552 717-492-0303 00 North Union Street Middletown, PA 17057 717-944-2225 845 Sir Thomas Court Suite 11 *sburg, PA 17109 717-652-4002 Amour .1 Last Name: AtIff_ .. First Name: Apr/ , MI: D.O.B: s. ---; - -- S: Recurrent Acut Sub -acute Exacerbation Chronic New complaint' Wellness DATE OF ONSET: • - . i - " --- / r lit024 A a 4- .v., , -7, ' - ca, ),„"4,‘, VAS P: in Scale I 2(a5 6 7 8 9 10 See DT. : k . ... 4 :.i. („ • 4 'X 7 A t en ri,e are. thy., 4- 1 -0-, , f See DT. Osseous Findin_ & Osseous Treatment (Maui. Wail° C 0 1 2 3 4 7 T I CD 3 ., 5 6 a 8 9 10 11 12 L 1 2 3 4 es) PR L B SR L B BP ixtraspinal: TH A ,. <1E..9:ME Cf' (E)JLT D TH A 0 F-3;16 P G D A ' V V V F S E P 0 SOT D TH A FSEPG D TH A SE. P H D TH A Soft Tissue Findings & Non -Osseous Treatment: TendertiO,sst3.4.0 T L EXTR / Tonicity 10 45 Ct, SO S-A / S -M S -P LS SCM 41 / T -M 1. T -L gL) EQT) <G. 2) Cel SP FR TP R SA T -MA / T -M1 SUB SS ' IS P -MA / W -E / E TP (1 2) P SP FR LP CID LD P G —MAX / G—MED / G--M1N TFL B. T H Q GAS PF () L) E ( 1 2) CD SP FR OTHER: E, TP ( 1 2) P SP FR 1/A AIR Mfit. DMM PNF Time: Min, Manual (g) TXN. Time: (2) MM. Other: IFC C,Z) RS SB : (57- Min (Patient Tolerance) l - 1(j2080 -l50 1-120 10-10 10-50 USP USC Min COLD I Min Skin Condition Today's Treatment: Watts / CM 2 20/5% 40/10% 60/15% 80/20% 100/25% ID Case Management Towards Resolution/ Stability of Patient's Condition: RED FLAG: Yes No The patient's current complaint, past medical history, prior surgeries, Medications; allergies, family historY;social history and review of systems are all well outlined in the adult's medical record and these were reviewed today. New TX Plan 11 -W -s -ii) Modify TX Plan:' End TX Plan Re-eval.Date: O Anticipated Treatment Plan: Days Weeks / Visit # of PRN O New Exercise Program Min. (See handout): tC06Dct O Nutritional Support 0 Home Instructions: 0 SENT O Taping / Strapping: , • Min Type of Tape Used: Region O DME / Supports / Appliances: DItd3'4012 O Studies: , Rationale: O Refer for outside services: Rationale: O All exam information entered in ASHN tx. plan (See ASHNform) Highmark tx. plan (See HM form) O Other: Consulted with the pa*.u.k, on the following:CrimAemove .tycva Facto / Alter Ergonomics @ Work/ Home / Lifestyle Modification / Rest Y N II.LHEPy Sleep Positions / Nutritional Counselin: Atite; / Contrast/ RICE / Smoking Cessation Goals: J. OAT Seorei/Symptoms by 30-50% by next evaluation/ Other. Add: Omit: D1AGNOSIS:/ NEW: Today's Notes: '1 . No Signature: 0 Ed Bartakovits Edward Hevn Dictated Note Discharge Dictated OAT Highmark / ASHN TX &Progress Note ACN form. D.C. David Carbo DC 0 Mary Colman DC 0 Scott Colman DC 0 Timothy Duke DC 0 Paul Hetrick DC C 0 Charlene Hobble DC 0 Ashley Viele DC • e fI irtpf 6 -ash, M. ` SPECIAL NOTATION: The Hetrick Centers CHIROPRACTOR SOAP NOTE d' a Tax Id.7.11 .610289 DATE: . 1300 Bent Creek Boulevard Mechanicsburg, PA 17050 717-796-2225 2oNorthBarbaraStreetMountJoy, PA 17552 717-492-0303 500 North Union'Street 114iddletoWn, PA 17057 717-944-2225 Sir Torn Stiite 11 . ibUr, PA 17109 717-65A-40 2 LastName: . First Name: MI: V D.O.B: Arz i • . S: Recurrent Acute /b -acute Exacerbation Chronic New complaint Welines D / ' OF ONSET: 1 ' at • 4-. - ' a /, 5,4i 0-.., ekt-e 1 VAS Pain Scale 1 2 3 4 5 6 89 10 See DT. : Lt ..1 F \ 1.- ... Ow 77,-. Cr m'i., e_ 1... See DT. Osseous Findings & Osseous Treatment (Manipulation) C 0 2 3 4 6 7 T 1 2 3 4 j, 7 8 9 10 11 12 L 1 2 3 4 (1.) PR L B SR L B BP xtraspinal:V -• .I, T D TH A -' 41114.. VFSEP V E (35) D A .P G 1-0 D A G SOT D TH A F. S E P G P. TH A F S E P H D TH A , Soft Tissue Findings & Non -Osseous Treatment : Tender :. AP ' 3' 4 C T L EXTR / TorncRtj3 45 CP SO S-A / S -M . / S -P LS. SCM :4ffink / T -M / T -L '1 -...--Zak E.) ( 1 2) P SP FR TP R,_ SA T -MA / T -MI SUB SS IS P -MA / P-IVII W -F / W -E ' (R / L) E TP ( 1 2 ) ' P SP FR LP 4L LD P G —MAX / G—MED / G—MIN TFL B T 1-1 Q GAS PF ( R / L) E TP ' ( 1 2) P SP FR OTHER; . E TP ( 1 2) P SP FR , . .. UA A/R M/R ' DMM PNF Time: - Min. Manual (0.-D TXN Time: C--) Min. •1 Other IFC (0) RS SB • PRE : IS— Min (Patient Tolerance) 1-10 , -20 80-150 1-120 10-10 10-50 USP USC Min @ Watts / CM 2 20/5% 40/10% 60/15% 80/20% 100/25% COLD I, S Min ' Skin Condition: Pre-INCial ost-Norm .. . Today's Treatment: Well Tolerate. N ,•. POST TX VAS 1 Case Management Towards Resolution / Stability Of Patient's Condition: RED FLAG: Yes No The patient's current complaint,past medical history, prior sfitgeries, medications, allergies, family history, social history and review of systems are all well outlined in the patient's medical record and these were reviewed today. New TX Plan Cont. TX Plan Modify TX Plan: End TX Ilan Re-eval.Date: 0 Anticipated Treatment Plan: Days CID Weeks / Visit # of PRN 0 New Exercise Program Min. (See handout): 0 Nutritional Support:. -.. 0 Home Instructions: CORDS ,. Say 0 Taping / Strapping: - : Min Type of Tape Used: - ody2R070. - T Bl 0 DME / Supports / Appliances: . DE c 8 0 Studies: Rationale: * ' 0 Refer for outside services: • . Rationale: . 0 All exam information entered in ASHN tx. plan (See ASHN form) Highmark tx. plan (See HM form 0 Other: Consulted with the pat on on the following: Limit/Remove Aggravatin Factors / Alter Ergonomics @ World Home / Lifestyle Modification f Rest Y N 4TFI Sleep Positions / Nutritional Counseling ICE / Contrast/ RICE / Smoking Cessation oals: 4. OAT Scores/Symptoms by 30 —50% by next evaluation/ Other: , D1AGNOSLS. Add: - Omit: __: Today's Notes: 1 ail Not Dictated Note Discharge Dictated OAT Highmark / ASHN TX &Progress Note AN form Signature: 1:„..---.--... , . . D.C. DJEd Baikovits DDavid Carbo DC 0 Mary Colman DC 0 Scott Colman DC 0 Timothy Duke DC 0 Paul Hetrick DC 710 C.4....4 1i,..,,. n oi.......i,....... L.L.-.1.3.;.1-10 17 A chlam, 'Violet no SPECIAL NOTATION: The Hetrick Centers 1300 Bent Creek Boulevard Mechanicsburg, PA 17050 717-796-2225 CHIROPRACTOR SOAP NOTE 20 North Barbara Street Mount Jay, PA 17552 717-492-0303 Tax 1 • 5- 640289 500 North Union Street Middletown, PA 17057 717-944-2225 DATE: c9 845 Sir Thomas Court Suite 11A, arrisburg, PA 17109 717-65 -4002 Last Name: , ,z,,,,..,' , First Name: MI:. , D.O.B: 7 S: Recurrent Acute eub-acute Exacerbation Chronic New complaint Wellness TE OF ONSET: a- * 4 . 1.vnr 6--f ,Sjl../if ; C7 :_ (''J - _./.. 5,�,,, 7 % C o J' VAS Pain Scale 1 2 4 6 7 8 9 10. See DT. ,,, o: 1-24 71-,21., - / a- 1 L ,-/b,rI. 7/ ? c iec", Ll ,z -/a S. 0,F---2) "v4. /bo./ S�,w-f vS .�„,./)/$/ oh/ .. . . . j- j, See DT. Osseous Findings & Osseous Treatment (Manipulation) C 0 1 2 3 4 4441 7 F S E! T D TH A T 1 C4 5 7 8 9 10 11 12 ' ANT D TH A L 1 2 3 4 e `l $3 G D L A PR L B S R L B BP Extraspinal:T V V F:: S E P G SOT D TH A F.S'E P G D TH A F. • S'.E P H D TH A Soft Tissue Findings & Non -Osseous Treatment SO S-A I. S -M / S -P LS : Tendernes SCM Irath. 4 C T L EXTR / Tonicity CD4 4 5 lie / T -M / T -L« % L 3 E D) <5 SP FR TP R SA T -MA / T -MI SUB SS IS P -MA / P -MI W -F / W -E (R / L) E TP (1 2) P SP FR LP `j D P G MAX / G—MED / G—MIN TFL B T H Q GAS PF ()L) E�� (1 2 )® SP FR OTHER: E TP (1 2) P SP FR I/A A/R M/R DMM PNF Time: Min. Manual ( ) TXN Timer Min, it 0 Other: P` IFC (V RS SB PRE : I T Min (Patient Tolerance) 1-10 -120 0-150 1-120 10-10 10-50 t_ USP USC Min @ Watts / CM 2 20/5% 40/10% 60/15% 80/20% 100/25% HO COLD (S�Min Skin Condition .'re -Norm. ost Norm Today's Treatment: Well Tolerated GD N POST TX VAS 0 Case Management Towards Resolution / Stability of Patient's Condition: RED FLAG: Yes No The patient's current complaint, past medical history, prior surgeries, medications, allergies, family histo sociis ew of systems are all well outlined in the .:, edical record and these were reviewed today, s RDS New TX Plan Cont. TX Plan Modify TX Plan: n `ia'.: ?'t : :1M ❑ Anticipated Treatment ' an: Days Weeks / Visit # of�E' 2 o New Exercise Program Min. (See handout): 4 2012 , DEC 2 ❑ Nutritional Support: 0 Home Instructions: ❑ Taping / Strapping: Min, Type of Tape Used: Body Region • "' " ".."" ❑ DME / Supports / Appliances: •" ' `' ❑ Studies: Rationale: ❑ Refer for outside services: Rationale: ❑ All exam information entered in ASHN tx. plan (See ASHN form) Highmark Ix. plan (See HMform) ❑ Other: Consulted with the pate the following: Limit/Remove Aggray. ', Factors / Alter Ergonomics (Q World Home I Lifestyle Modification / Rest Y N / Sleep Positions / Nutritional Counseling = CE ! Contrast/ RICE / Smoking Cessation Goals: 4 OAT Scores/Symtoms by 30 —50% by next evaluation/ Other: DIAGNOSI ,'.. Add: Omit: Today's Not Dom, a ictated Note Discharge Dictated OAT Highmark / ASHN TX &Progress Note ACN form Signature: � D.C. d Bartakovits DC ODavid Carbo DC 0 Mary Colman DC 0 Scott Colman DC 0 Timothy Duke DC 0 Paul Hetrick DC EC Edward Hevner i;C 0 Charlene Hobbie DC 0 Ashley Viele DC SPECIAL NOTATION: The Hetrick Centers 1300 Bent Creek Boulevard Mechanicsburg, PA 17050 717-796-2225 CHIROPRACTOR S SAP NOTE 20 North Barbara Street Mount Joy, PA 17552 717-492-0303 Tax Id: 5-16' 1 r 8 500 North Union Street Middletown, PA 17057 717-944-2225 DATE: 1 845 Sir Thomas Court Suite 1 A, Harrisburg, PA 17109 717-652-4002 Last Name: ��,� \al.. F\ First Name: N L MI: D.O.B: ' S: Recurrent Acute Sub-acute Exacerbation Chronic New com aint Wellness D TE OF O SET: te_sl a A n L 1l (,z_ (.4.44_--1 f e Lea- �,.,�� 0,1-- P� �., � �< <��� LA. G.o I. .lam.,�, - 1r tP Yr) _�� L C VAS Pain Scale 1 2 3 4 5 6 7 0 See DT. 0: A 1 See DT. Osseous Findings & Osseous Treatment (Manipulation) C 0 1 2 3 4 7 FSE® Qb T D TH A T 10) 36)5G 7 8 9 10 11 12 G—F ECD ANT D TH A L 1 2 3 4( PR LB SRL B P • • ._ FS3E4I3 G % D (Ta) A FSEP G SOT D TH A FSE P G D TH A Extraspinal: £ l 1, a, p� fia,c_ Q--- F. S E—Pj E$ D TH A Soft Tissue Findings & Non-Osseous Treatment : TendernessZ3 4 C T L EXTR / Tonici 4 4 5 C� SO S-A / S-M / S-P LS SCM <121 / T-M / T-L 4015 E' a2 ):' SP FR TP R SA T-MA / T-M1 SUB SS IS P-MA / P-MI W-F / W-E (R / L) E TP (1 2) P SP FR LP cJ.,D P G —MAX / G—MED / G—MIN TFL B T H Q GAS PF (ML) E ® (1 2 SP FR OTHER: E TP 2) P SP FR /(1 I/A A/R M/R DMM PNF Time: Min. Manual TXN Tim ) Min. Other: r /114 IFC tZ., RS SB PRE : / Min (Patient Tolerance) 1-1 c :0-121 80-150 1-120 10-10 10-50 USP USC Min @ Watts / CM 2 20/5% 40/10% 60/15% 80/20% 100/25% ICOLD Min Skin Condition . • e- ormal / Post-Norm. Today's Treatment: Well Tolerated CD N POST TX VAS ❑ Case Management Towards Resolution / Stability of Patient's Condition: RED FLAG: Yes No The patient's current complaint, past medical history, prior surgeries, medications, allergies, family history, social history and review of systems are all well outlined in the patient's medical record and these were reviewed today. -le New TX Plan Cont. TX Plan Modify TX Plan: End T ❑ Anticipated Treatment Plan: Days C Weeks / Visit # of ❑ New Exercise Program _ Min. (See handout): o j a • to, Nutritional Support: ■ Home Instructions: • Taping / Strapping: Min Type of Tape Used: Body Region • DME / Supports / Appliances: ❑ Studies: Rationale: ❑ Refer for outside services: Rationale: ❑ All exam information entered in ASHN tx. plan (See ASHN form) Highmark tx. plan (See HM form) ❑ Other: Consulted with the patient on the following: Limit/Remove Aggravatin Factors / Alter Ergonomics @ Work/ Home / Lifestyle Modification / Rest Y N / IHEP / Sleep Positions / Nutritional Counseling rl CE / Contrast/ RICE / Smoking Cessation Goals: .j. OAT Scores/Symptoms by 30 —50% by next evaluation/ Other: DIAGNOSI'• 411 . • . Add: "7 / 7, y?, Omit: Today's Not = • Pall .•i- Dictated Note Discharge Dictated OAT Highmark / ASHN TX &Progress Note ACN form Signature: -�_,.._ D.C. ❑ Ed Bartakovit i C ODavid Carbo DC 0 Mary Colman DC ❑ Scott Colman DC 0 Timothy Duke DC 0 Paul Hetrick DC AFdward Hey - r DC 0 Charlene Hobbie DC 0 Ashley Viele DC LSPECIAL NOTATION: The Hetrick Centers 1300 Bent Creek Boulevard Mechanicsburg, PA 17050 717-796-2225 CHIROPRACTOR SOAP NOTE 20 North Barbara Street Mount oy, PA 17552 717-492-0303 Tax Id: 5-161289 500 North Union Street Middletown, PA 17057 717-944-2225 DATE: A 845 Sir Thomas Court IA, Harrisburg, PA 17109 717- -4002 tute Last Name: A.. f %I First Name: I MI._____ D.O.B. .,_.A% S: Recurrent Acute Sub-acute xa ation Chronic New complain Wellness DATE OF ONSET: s I.4 Pr i4icZr / a d- * _ , . , • * _ , a VAS Pain Scale 2 5 6 7 8 9 0 See DT. 0: 5 ' - - A , . ' - See DT. Osseous Findings & Osseous Treatment (Manipulation) C 0 1 2 3 4 CMID 7 F S E TH T 1 (1 3 4 0 6 7 a 9 10 11 12 ' E ANT D TH A L 1 2 3 Ca> PR LB SR L B BP C-7--IECLIstG • • D TH A FSEP G SOT D TH A FSEP G D TH A Extraspinal: L,1--0,14 c.-4,--- 11_• ,– _ F S E D TH A Soft Tissue Findings & Non-Osseous Treatment : Tenderness/1 4 C T L EXTR / Tonicity 1Y3 4 5 (1) SO S-A / S-M / S-P LS SCM (II / T-M / T-L ) E c' 10,2 ) -''' SP FR TP R SA T-MA / T-MI SUB SS IS P-MA / P-MI W-F / W-E (R / L) E TP (1 2) P SP FR LP QL LD P G —MAX / G—MED / G—MIN TFL B T H Q GAS PF (R / L) E TP (1 2) P SP FR OTHER: E TP (1 2) P SP FR 1/A A/R M/R DMM PNF Time: MM, Manual TXN Time: C-Z MM. Other: IFC CI&) RS SB PRE : / 5---- Min (Patient Tolerance) 1- 0-1 80-150 1-120 10-10 10-50 USP USC MM @ Watts / 6.4 2 20/5% 40/10% 60/15% 80/20% 100/25% 4Mal COLD / 5— Min Skin Condition • Pre-No al / ost-Normal Today's Treatment: Well Tolerated &.) N POST TX VAS o Case Management Towards Resolution / Stability of Patient's Condition: RED FLAG: Yes No The patient's current complaint, past medical history, prior surgeries, medications, allergies, fantirEMI, social history and review of systems , are all well outlined in th nt's medical record and these were reviewed to :' - a.------ . • • New TX Plan • Modify TX Plan: c.; .-End,TX Plan Re-eval.Date: CI Anticipated Treatment Plan: Days Weeks / Visit LI NewExercise Program Min. (See handout): D Nutritional Support: CI Home Instructions: El Taping / Strapping: Min Type of Tape Used: Body Region 0 DME / Supports / Appliances: El Studies: Rationale: 0 Refer for outside services: Rationale: 0 All exam information entered in ASHN tx. plan (See ASHN form) Highmark tx. plan (See HMform) 0 Other: Consulted with the patient on the following: Limit/Remove Aggravating Fa ors / Alter Ergonomics @ Work/ Home / Lifestyle Modification / Rest Y N / [HEP / Sleep Positions / Nutritional Counseling / Hea Contrast/ RICE / Smoking Cessation Goals: 4. OAT Scores/Symptoms *y 30 –50% by next evaluation/ Other: DIAGNOSIS. - W: Add: Omit: Today's Notes: tb • No Dictated Note Discharge Dictated OAT Highmark / ASHN TX &Progress Note ACN form Signature: D.C. d Bartakovits i DDavid Carbo DC 0 Mary Colman DC 0 Scott Colman DC 0 Timothy Duke DC El Paul Hetrick DC JaEdward Hev. -r DC 0 Charlene Hobbie DC 0 Ashley Viele DC OR Bush :Fax: 17-561-8388 Oct 28 2014 02:28pm P006/018 - • ATE CHIEF COMPLAINT - ADDITIONAL HISTORY; PHYSICAL FINDINGS _ - -_- MEDICATIONS Ma O�#Y (Y�. Uv�i� _t ,A',,- SPECIAL NOTATION: The Hetrick Centers CHIROPRACTOR SOAP NOTE Tax Id: 25-1g40289 DATE: 1, -\J 1300 Bent Creek Boulevard Mechanicsburg, PA 17050 717-796-2225 20 North Barbara Street Mount Joy, PA 17552 717-492-0303 500 North Union Street Middletown, PA 17057 717-944-2225 Last Name: 845 Sir Thomas Court Suite 11A, Harrisburg, PA 17109 717-652-4002 First Name: MI: D.O.B: _4413 S: Recurrent Acute Sub -acute Exacerbation Chronic New complaint Wellness DATE OF ONSET: VAS Pain Scale 1 205 6 7 8 9 10 c ee DI) Osseous Findings & Osseous Treatment (Manipulation) C 0 1 2 3 4(6 7 T 1® 3 4® 6 7 8 9 10 11 12 L 1 2 3 4 Q P R L B S R L B BP Extraspinal: • • • • TH A E P ( ANT D TH A S E1 G ® D A FSE P G SOT D TH A FSE P G D TH A F:$ IE P H D TH A Soft Tissue Findings & Non -Osseous Treatment : Tendernes® 2 3 4 C T L EXTR / TonicityrD 3 4 5 CP SO S-A / S -M / S -P LS SCM / T -M / T -L Oa)) E CO C)2) SP FR TP R SA T -MA / T -MI SUB SS IS P -MA / P -MI W -F / W -E (R / L) E TP (1 2) P SP FR LP QL LD P G —MAX / G—MED / G—MIN TFL BTHQ GAS PF (R / L) E TP (1 2) P SP FR OTHER: E TP (1 2) P SP FR I/A A/R M/R DMM PNF Time: Min. Manual TXN Time: Min. Other: IFC Q RS SB PRE : /' Min (Patient Tolerance) 1-1 t7)--1-2380-150 1-120 10-10 10-50 USP USC Min @ Watts / CM 2 20/5% 40/10% 60/15% 80/20% 100/25% H071) COLD Min Skin Condition . re -None Today's Treatment: Well Tolerated N POST TX VAS Case Management Towards Resolution / Stability of Patient's Condition: RED FLAG: Yes No The patient's current complaint, past medical history, prior surgeries, medications, allergies, family history, social history and review of systems are all well outlined in the patient's medical record and these were reviewed today. New TX Plan Cont. TX Planodify TX Pia End TX Plan Re-eval.Date: t Anticipated Treatment Plan: 1 Days 3 Weeks / Visit # of PRN ❑ New Exercise Program _ Min. (See handout): ���� ❑ Nutritional Support: 0 Home Instructions: ❑ Taping / Strapping: Min Type of Tape Used: BodyAllge ioOn 2013 ElDME / Supports / Appliances: ❑ Studies: Rationale: ❑ Refer for outside services: Rationale: ❑ All exam information entered in ASHN tx. plan (See ASHN form) Highmark tx. plan (See HM form) ❑ Other: Consulted with the patient on the following: Limit/Remove Aggravating Factors / Alter Ergonomics @ Work/ Home / Lifestyle Modification / Rest Y N / ci i Sleep Positions / Nutritional Counseling / He. (i Contrast/ RICE / Smoking Cessation Goals, 1 OAT Scores/Symptoms by 30 —50% by next evaluati Other: DIAGNOSI / NEW Today's 'Notes' I Signature: Add: Omit: Dictated Note Discharge Dictated OAT Highmark / ASHN TX &Progress Note ACN form D.C. ❑ Ed Bartakovits C ❑David Carbo DC 0 Mary Colman DC 0 Scott Colman DC ❑ Timothy Duke DC 0 Paul Hetrick DC Edward Hey er DC 0 Charlene Hobbie DC 0 Ashley Viele DC THE HETRICK CENTER You have a choice for Physical Therapy...c hoose us! 500 North Union Street 1300 Bent Creek Boulevard 20 North Barbara Street 845 Sir Thomas Court, Suite 1 IA Middletown, PA 17057 Mechanicsburg, PA 17050 Mount Joy, PA 17552 Harrisburg, PA 17109 Office: (717) 944-2225 Office: (717) 796-2225 Office: (717) 492-0303 Office: (717) 652-4002 Fax: (717) 944-0932 Fax: (717) 796-2229 Fax: (717) 492-0309 Fax: (717) 652-4005 January 10, 2013 Harrisburg RE: Leslie Glazer DOB: 03/07/1980 PI CLINICAL HISTORY Ms. Glazer presents today for a reevaluation and treatment for injuries sustained in a motor vehicle accident. She has been compliant with care. She has missed several appointments on occasion due to either sickness and/or an incredibly busy schedule with school, child activities, and/or work. She continues to complain of neck pain which does vary in intensity. She notes her pain today is a 4/10. She also complains of bilateral upper extremity and hand numbness, which she also notes has improved with the addition of treatment to her elbow, particularly on the left side. She has had three days without any numbness at this point, after her last treatment. She notes that she is able to perform most of her ADL activities but does have a slowing and quicker fatigue with several activities involving prolonged sitting and/or carrying laundry, which tends to fatigue her upper back and neck. She does have to rest more frequently than she did prior to her motor vehicle accident. She notes that she does have some limited ranges of motion noticed while driving, particularly in reverse trying to back up out of her driveway with left rotation. PAST MEDICAL HISTORY The patient's past medical history, prior surgeries, medications, allergies, family history, social history, and a complete review of systems were done with the patient, and pertinent positives and negatives are recorded in the paper chart and the rest in the HPI. PHYSICAL EXAMINATION Range of motion study today of the cervical spine did cause and reproduce restriction with flexion only 10% loss with general stiffness and mild pain noted over the cervical thoracic junction. Right rotation was decreased 10%. Left rotation was decreased 10%, as well and had pain and stiffness noted with the lower portion of the cervical spine. Bilateral lateral flexion was decreased 10% with general stiffness in the neck in particular. Mild positive pain reproduction with left Jackson's compression, which reproduced pain locally at the lower portion of the cervical spine on the left side, elevated muscle tonicity of the left trapezius muscle with a +2 in multiple trapezius trigger points. A large, rather tender mid right trapezius muscle trigger point was also noted. Isometric resistance caused no increased pain at this time. Passive stretching to the trapezius muscles bilaterally did cause proximal to mid portion trapezius muscle pain increase. She continues to have edema formation around the posterior elements of C5 through C7 THE HETRICK CENTER Leslie Glazer Page 2 of 2 January 10, 2013 with some tenderness over the spinous process noted minimally at a +1. Lumbar ranges of motion were full with some end range pain noted as mild in extension and flexion at the lower lumbar spine. Mild edema formation does persist over the posterior element of L5. Orthopedic testing is done, negative in the lower lumbar spine. Deep tendon reflexes and myotomes were normal in the upper and lower extremities. TREATMENT PLAN The patient was treated today with electric muscle stimulation, heat, manual traction, passive stretching to the paraspinals of the cervical spine and the appropriate specific adjustments. Patient will continue care at one time per week for the next three weeks followed with a reevaluation and determination for our continued care at that point. It is my professional opinion, within a reasonable degree of chiropractic certainty, that the subjective complaints brought forth by the patient and my examination findings do continue to coincide with the motor vehicle accident. Please see all previous dictations, etc., for details surrounding the motor vehicle accident with dates. Patient will follow-up in approximately 1 week for additional treatment. I did advise her to continue icing the areas especially on days where she is very active, changing positions at work and at school as readily as possible and performing her independent home exercises programs. I do hold the same diagnosis. I believe we will be reducing her care to only regions of the cervical and upper back. Prognosis remains good. Patient is progressing. Continued goal is remain at full reduction of the pain in the cervical spine and reducing the radicular pain in e left upper extremity to above the elbow. Edward evner, D.C. EL lSPECIAL NOTATION: The Hetrick Centers CHIROPRACTOR SOAP NOTE i . -1640289 DATE: Last Name: 1300 Bent Creek Boulevard Mechanicsburg, PA 17050 717-796-2225 20 North Barbara Street Mount Joy, PA 17552 1717-492-0303 500 North Union Street Middletown, PA 17057 717-944-2225 845 Sir Thomas Court Suitg 11A, Harrisburg, PA 17109 717-652-4002 MI: D.O.B2) ` 1 First Name: S: Recurrent Acute Sub -act Exacerbation Chronic New complaint Wellness 1 DATE 0 ONSET: z VAS Pain Scale 1 23456789 10 See DT. 1r.( F -N.. l; d♦ ti i AJ to RA- -fear rho/ —1 T.ei 'ref/ See DT. Osseous Findings & Osseous Treatment (Manipulation) C 0 1 2 3 43D 7 T 1d2)3Go5 6 4 8 9 10 11 12 L 1 2 3 4 P R L B S R L B BP Extraspinal: SR L BB?' F S E S -)E • FSE P G • FSE P G Cf— FSE PJ. <ID SOT D TH A D TH A D 1'HH A D TH A D TH A D TH A Soft Tissue Findings & Non -Osseous Treatment : Tenderness/1d) 4 C T L EXTR / Tonicity 14 5. CP SO S-A / S -M / S -P LS SCM T- / T -M / T-L®L) E(j) SP FR TP R SA T -MA / T -MI SUB SS IS P -MA / P -MI W -F / W -E (R / L) E TP (1 2) P SP FR LP QL LD P G —MAX / G—MED / G—MIN TFL B T H Q GAS PF (R / L) E TP (1 2) P SP FR OTHER: E .TP (1 2) P SP FR I/A A/R M/R DMM PNF Time: Min. Manual () TXN Time: (R.) Min. Other: IFC USP RS SB PRE : f! Min (Patient Tolerance) I-1 f3().) 80-150 1-120 10-10 10-50 USC Min @ Watts / CM 2 20/5% 40/10% 60/15% 80/20% 100/25% Q 1 COLD Jr". Min Skin Condition Pre -/mal / ' st-Normai Today's Treatment: Well Tolerated N N POST TX VAS ❑ Case Management Towards Resolution / Stability of Patient's Condition: RED FLAG: Yes No The patient's current complaint, past medical history, prior surgeries, medications, allergies, fainly history, social history and review of systems are all well outlined in the patient's medical record and these were reviewed today. New TX Plan Cont. TX Plan Modify TX Plan: End TX Plan Re-eval.Date: ❑ Anticipated Treatment Plan: Days Weeks / Visit # of PRN ❑ New Exercise Program Min. (See handout): -RECORDS SFNT ❑ Nutritional Support: 0 Home Instructions: ❑ Taping / Strapping: Min Type of Tape Used: BO@elan 13 El DME / Supports / Appliances: ❑ Studies: Rationale: ❑ Refer for outside services: Rationale: ❑ All exam information entered in ASHN tx. plan (See ASHN form) Highmark tx. plan (See HMform) ❑ Other: Consulted with the patient on the following: Limit/RemoveAggravatin• Factors / Alter Ergonomics @ Work/ Home % Lifestyle Modification / Rest Y N / IHEP / Sleep Positions / Nutritional Counseling / CE / Contrast/ RICE / Smoking Cessation Goals: j OAT Scores/Symptoms by 30 50% by next evaluation/ Other: DIAGNOSIS Today's Note Signature: NEW: Add: Omit: Dictated Note Discharge Dictated OAT Highmark / ASHN TX &Progress Note ACN form D.C. ❑ Ed Bartakovits D ' ❑David Carbo DC 0 Mary Colman DC 0 Scott Colman DC 0 Timothy Duke DC 0 Paul Hetrick DC Edward Hevne DC 0 Charlene Hobbie DC 0 Ashley Viele DC SPECIAL NOTATION: The Hetrick Centers 1300 Bent Creek Boulevard Mechanicsburg, PA 17050 717-796-2225 CHIROPRACTOR SOAP NOTE 20 North Barbara Street Mount PA 17552 717-492-0303 T... I :rr25n-1641.89 500 North Union Street Middletown, PA 17057 717-944-2225 l DATE: /' Q.- 845 Sir Thomas Court Sui A, Harrisburg, PA 17109 717-652-4002 L Last Name: `- , Ix a i ' First Name: MI: D.O.B: S: Recurrent Acute Sub -acute Exacerbation Chronic New com laint Wellness DAOF ONSET: .r L -4.s 1 ti r 0L < e/.:., 1 l . /U4c..t4 C } d f` � ," '. 0'l ' (,/, € ;fie . . - (11)L- d-- �1 „ Se „ U4. I- f/1>3r penJ WAS Pain Scale 1 25 6 7 8 9 10 See DT. 0: •/Y1•....1 Cl v:J A. Li'�r.l �Sl r d . ` St, i\ (, See DT. Osseous Findings & Osseous Treatment (Manipulation) C 0 • F S E ® T D TH A T C) 3 ais 5 6 7 ®9 10 11 12S E ® ANT D TH A L 1 2 3 4 d PR L B SR L B BP Extraspinal: V • V E G/D D A FSE P G CS D TH A FSE P G D TH A F *S'E P H D TH A Soft Tissue Findings & Non -Osseous Treatment CP SO S-A / S -M / S -P LS TP R SA T -MA / T -MI SUB SS IS LP QL LD P G MAX / G—MED / G—MIN OTHER: : Tendern SCM P -MA TFL 2 3 4 C T L EXTR / Tonici 41 4 5 •1 / T -M / T -L 'I 6 E Tin (cP 2) SP FR / P -MI W -F / W -E (R / L) E TP (1 2) P SP FR B T H Q GAS PF (R / L) E TP (1 2) P SP FR E TP (1 2) P SP FR 1/A A/R M/R DMM PNF Time: Min. Manual �c TXN Time: Min. 0 Other: IFC let1 RS SB .PRE: / S— Min (Patient Tolerance) 1-10 <Mb 80-I50 1-120 10-10 10-50 USP USC Min ® Watts / CM 2 20/5% 40/10% 60/15% 80/20% 100/25% 11 COLD 15' Min Skin Condition : m Norm '• . -. orm. Today's Treatment: Well ToleratedY N POST TX VAS IN Case Management Towards Resolution / Stability of Patient's Condition: RED FLAG: Yes No , The patient's current complaint, past medical history, prior surgeries, medications, allergies, family history, social history and review of systems are all well outlined in the patient's medical .. d and these were reviewed today. New TX Plan Cont. TX Plan iik odify TX P a : End TX Plan Re-eval.Date: ❑ Anticipated Treatment Plan: Days d Weeks / Visit # of P ■ New Exercise Program Min. (See handout): Re- 1`g / . A( e v/- 4f., _ ❑ Nutritional Support: Il Home Instructions: - • Taping / Strapping: Min Type of Tape Used: Body' MI DME / Supports / Appliances: ❑ Studies: Rationale:.FEB ®6 Z013 Refer for outside services: Rationale: ❑ All exam information entered in ASHN tx. plan (See ASHN form) Highmark tx. plan (See HM form) ❑ Other: Consulted with the patient on the following: Limit/Remove Aggravatin actors / Alter Ergonomics @ World Home / Lifestyle Modification / Rest Y N / IHEP / Sleep Positions / Nutritional Counseling/ 4i' ICE / Contrast/ RICE / Smoking Cessation Scores/Symptoms by 30 -50% by next evaluation! Other. Goals: j OAT It-4M Add: Omit: DIAGNOSIS:• i : Today's Notes Dail N. ° Dictated Note Discharge Dictated OAT Highmark / ASHN TX &Progress Note ACN form Signature: D.C. IC] pi Bartakovi i C 'David Carbo DC ■ Mary Colman DC ■ Scott Colman DC ❑ Timothy Duke DC 0 Paul Hetrick DC rf.Y ______I . v_ -_ nr n r'h,rIfine l -,11 -hie DC 0 Ashley Viele DC • SPECIAL NOTATION: The Hetrick centers 1300 Bent Creek ul d Mechanicsburg PA 17050 717-796-2225 CHLROPRA TOp. SOAP NOTE 20 North Barbara Street Mount Joy, PA 17552 717-492-0303 Tax 14 251 289 500 North Union Street Middletown, PA 17057 717-944-2225 DATE: 62-- 1 845 Sir Thomas Court ' 11A, Harrisburg, PA 17109 717-6 -4002 , I Last Name: First Name: th,Q.0„2_ M1:*D.O.B: _ S: Recurrent Acute Sub -ate Exacerbation Chronic New complaint Wellness DATE ONSET: - VAS Pain Scale 1 2 36)5 6 789 10e1. . : . DT Osseous Findings& Osseous Treatment(Manipulation) C 0 1 246 7 T I 11,25 3 a 5 CO 7 8 9 10 11 12 L 1 2 3 4 5 PR LB SR L B BP Extraspinal: (E....EDE • • • V T TH di)( ANT D TH A FSEP G TH A FSEP G SOT D TH A FSEP G D TH A F S E P H D . TH A Soft Tissue Findings & Non -Osseous Treatment CP SO S-A / S -M / S -P LS TP R SA T -MA / T -MI SUB SS IS LP QL LD P G —MAX / G—MED / G—MIN OTHER: : Tenderness/I6'1 SCM P -MA t'FL 4 CT L EXTR / Tonicity K74 62) / T -M / T -L (e* L) E CID (02 ) 1:21SP FR / P -MI W -F / W -E (R / L) E TP ( 1 2) P SP FR B T H Q GAS PF ( R / L) E TP ( 1 2) P SP FR E TP ( 1 2) P SP FR 1/A A/R M/R DMM PNF Time: Min. Manual <Th TXN Time: CP) Min. Other IFC ,E3, RS SB PRE: / S--- Min (Patient Tolerance) 1-10 80-121:0-11-120 10-10 10-50 , USP USC Min @ Watts / 6m 2 20/5% 40/10% 60/15% 80/20% 100/25% ti'itf al COLD /6" --Min Skin Condition: re -No . Today's Treatment: Well Tolerated N POST TX VAS Case Management Towards Resolution / Stability of Patient's Condition: RED FLAG: Yes No The patient's current complaint, past medical history, prior surgeries, medications, allergies, family history, social history and review of systems 1, are all well outlined in the patient's medical record and these were reviewed today. New TX Plan Cont. TX Plan Modify TX Plan: End TX Plan Re-eval.Date: Anticipated Treatment Plan: Days Weeks / Visit #, p•-37, of–A (i rff5‘PRN- r .p,)i--- n. (See handout): iL3 , ' – 0 New Exercise Program Mi0 ED Nutritional Support: 0 Home Instructions: AO 1 1 LU 0 Taping / Strapping: Min Type of Tape Used: Body Region 0 prE / Supports / Appliances: 0 Studies: Rationale: 0 Refer for outside services: Rationale: 0 All exam information entered in ASHN tx. plan (See ASHN form) Highmark tx. plan (See HMform) 0 Other. Consulted with the padent on the following: Limit/Reinove Aggravating Factors / Alter Ergonomics @ Work/ Home / Lifestyle Modification / Rest Y N TIHEP / Sleep Positions / Nutritional Counseling / Heat/ ICE / Contrast/ RICE / Smoking Cessation Goals: 1 OAT Scores/Symptoms by I, —50% by next evaluation/ Other: DIAGNOSIS: SAME / NEW- Add: Omit: ' 737,3 Today's NotesZ e .:ed No Discharge Dicta'.. OAT ighmark / ASHN TX &Progress Note ACN form Signature: D.C. 0 i Bartakovits DC II i avid Carbo DC 0 Mary Colman DC 0 Scott Colman DC 0 Timothy Duke DC 0 Paul Hetrick DC Edward Hevner 6 C 0 Charlene Hobble DC 0 Ashley Viele DC NECK PAIN DISABILITY QUESTIONNAIRE The Hetrick Center Please Read: This questionnaire is designed to enable us to understand how much your neck pain has affected your ability to manage your everyday activities. Please answer each section by circling the one choice that most applies to you. We real- ize that you may feel that more than one statement may relate to you, but PLEASE JUST CIRCLE THE ONE CHOICE WHICH MOST CLOSELY DESCRIBES YOUR PROBLEM RIGHT NOW. SECTION 1 — Pain Intensity A. I have no pain at the moment. B.Thepain is very mild at the moment. . The pain is moderate at the moment D. The pain is fairly severe at the moment. E. The pain is very severe at the moment F. The pain is the worst imaginable at the moment. SECTION 2— Personal Care 0 I can look after myself normally without causing extra pain. B. I can look after myself normally, but it causes extra pain. C. It is painful to look after myself and I am slow and careful. r D. I need some help, but manage most of my personal care. E. I need help every day in most aspects of self-care. ' I do not get dressed, I wash with. difficulty and stay in bed. SECTION -3--- Lifting A. I can lift heavy weights without extra pain. • I can lift heavy weights, but it causes extra pain. Pain prevents me from lifting heavy weights off the floor, but I can manage if they are eonVeniently positioned, on a table. ,• • ;' D. Pain prevents me from lifting heavy weights off the floor, but I can manage light to medium weights if they are con- • veniently "positioned: ' • E. I can lift very light Weights. ' F. I cannot lift or carry'anything at all. •SECTION 4 —Reading I can read as much as I want to with no pain in my neck. ' I can read as much aS rwant to with slight pain in my neck. can read as much as Iwant with moderate pain in my neck. . • I cannot read as much -as I want because of moderate:paiii:in my neck.. : : ; • : - I cannot read as muchas I want becauseof severe pain in my neck. I cannot read at all. SECTION 5'1-41eadaches D. E. A. I have no headaches at all. I have slight headaches, which come infreqUently. have moderate headaches, which come infrequently. 1). I have inoderate headaches, which come frequently. , E. I have severe headaches, which frequently. P. I have headaches almost all of the dine: SECTION 6— Concentration A. I can concentrate fully when I want to with no difficulty. B. I can concentrate fully when I want to with slight difficulty. I have a fair degree of difficulty in concentrating when I want to. I -have a lot of difficulty in concentrating when I want to. I have a great deal of difficulty in concentrating when I want to. I cannot concentrate at all. D. E. F. SECTION 7— Work I can do as much work as I want to. I can only do my usual work, but no more. . I can do most of my usual work, but no more. D. I cannot do my usual work. E. lean hardly do any work at all. F. I.Cannot do any work at all. SECTION 8—Driving can drive my car without any neck pain. can, drive my car as long as I want with slight pain in my neck C.: I can drive my car as long as I want with moderate pain in my neck. D. cannot drive my car as long as -I want because of moderate pain in my neck E. I can hardly drive at all because of severe pain in my neck. F. I cannot drive my car at alL SECTION 9 — Sleeping. I have no trouble sleeping: • My sleep is slightly disturbed (less than 1 hour sleepless). My sleep is Mildly disturbed (1-2 hours sleepless). . My sleep is moderately disturbed (2-3 hours sleepless). • My sleep is greatly disturbed (3-5 hours sleepless). • My sleep is completely dispirbed (5-7 hours sleepless). SECTION 10 —Recreation I am able to engage in all df my recreational activities, with no neck painatilL aniable to engage in au of my recreational activities, with some Pain In mY neck C. I am able to engage in most, but not all of my usual recreational activities because of pain in, my neck. P. I am able to engage in a few of my usual recreational activities be- cause ofpain in iny neck. E. I can'hardly do any recreational activities because of pain in my neck. , F. I cannot ao any recreational attivities at all. atient's Signature Score: 21 6 7- • Date ?-3 AftVernon & Mior, 1991 Reprinted by perndssion of the Journal of er : Manipulative and Physiological Therapeutics - • The Hetrick Center ease Read: This questio F ityto manage your eve We realize that you may feel WI HICH MOST CLOSELY D VISED OSWESTRY CHRONIC LOW BACK PAIN DISABILITY QUESTIONNAIRE re is designel to enable us to understand how much your low back pain has affected your activities. Please answer each section by circling the one choice that most applies to you. t more than one statement may relate to you, but PLEASE JUST CIRCLE THE ONE CHOICE YO 1U t PROBLEM RIGHT NOW. C. D. E. F. B. D. E. F. ION 1— Pain Intensity e pain comes and goes and is The pain is mild and does not The pain comes and goes The pain is moderate and does The pain comes and goes and is The pain is severe and does not 0 2 -- Personal Care I would not have to change my order to avoid pain. I do not normally change my though it causes some pain. Washing and dressing increases change my way of doing it. Washing and dressing increases change my way of doing it. Because of the pain, I am unabl without help. Because of the pain, I am unab without help. SECTION 3 — Lifting I can lift heavy weights with I can lift heavy weights, but i Pain prevents me from lifting Pain prevents me from lifting but I can manage if they are c on a table. Pain prevents me from lifting age light to medium weights tioned. F. I can only lift very light wet SECTION 4—Viiate' g D. C. D. E. F. • mild. uch. U vere. ary much. y of washing or dressing in of washing or,dressing even e pain, but I manage not to e pain and I find ft necessary to do some washing and dressing do any washing or dressing extra pain. causes extra pain. heavy weights off the floor. envy weights off the floor, nveniently positioned, e.g., envy weights, but I can man - they are conveniently posi- at the most. not prevent me ft walking any distance. Pain prevents me from walkin more than one mile. Pain prevents me from . i i more than 12 mile. Pain prevents me from welkin _ more than 1/4 mile. I can only walk while using a or on crutches. I am in bed most of the time • d have to crawl to the toilet. SECTION 5 —Sitting R. I can sit in any chair as Iong . - I like without pain. (;)I can only sit in my favorite c a air as long as I hire. Pain prevents me from sitting i ' ore than one hour. D. Pain prevents me from sitting ore than 1/2 hour. E. Pain prevents me from sitting ore than ten minutes. F. Pain prevents me from sitting . all. SECTION 6 — Standing can stand as long as I want without pain. have some pain while standing, but it does not increase with tirili I cannot stand for longer than one hour without increasing pain. IX I cannot stand for longer than 1/2 hour without increasing pain. E. I cannot stand for longer than ten minutes without increasing pain. F. I avoid standing because it increases the pain straight away. SECTION 7 — Sleeping I get no pain in bed. I get pain in bed, but it does not prevent me from sleeping well. C. Because of pain, my normal night's sleep is reduced by less than D. Because of pain, my normal night's sleep is reduced by less than 1, E. Because of pain, my normal night's sleep is reduced by less than F. Pain prevents me from sleeping at all. SECTION 8 — Social Life My social life is normal and gives me no pain. My social life is normal, but increases the degree of my pain. C. Pain has no significant effect on my social life apart from limiting my more energetic interests, e.g., dancing, etc. D. Pain has restricted my sgcial life and I do not go out very often. B. Pain has restricted my social life to my home. F. I have hardly any social life because of the pain. SECTION 9 — Traveling I get no pain while traveling. I get some pain while traveling, but none of my usual forms of travel make it any worse. I get extra pain while traveling, but it does not compel me to seek alternative forms of travel. D. I get extra pain while traveling, which compels me to seek alterna- tive forms of travel. • Pain restricts all forms of travel. F. Pain prevents all forms of travel except that done lying down, S M ON 10 — Changing Degree of Pain My pain is rapidly getting better. My pain fluctuates, but overall is definitely getting better. C. My pain seems to be getting better, but improvement is slow at present. My pain is neither getting better nor worse. My pain is gradually worsening. My pain is rapidly worsening. C. D. E. F. Score: atient's Signature . ' `� Date °2) ( /15 From: N. Hudson, R Tome -Nicholson, A. Breen; 1989 THE HETRICK CENTER You have a choice for Physical Therapy...c hoose us! 500 North Union Street 1300 Bent Creek Boulevard 20 North Barbara Street 845 Sir Thomas Court, Suite 11A Middletown, PA 17057 Mechanicsburg, PA 17050 Mount Joy, PA 17552 Harrisburg, PA 17109 Office: (717) 944-2225 Office: (717) 796-2225 Office: (717) 492-0303 Office: (717) 652-4002 Fax: (717) 944-0932 Fax: (717) 796-2229 Fax: (717) 492-0309 Fax: (717) 652-4005 February 11, 2013 Harrisburg RE: Leslie Glazer DOB: 03/07/1980 PI CLINICAL HISTORY Ms. Glazer presents to The Hetrick Center of Harrisburg today for a reevaluation to determine her current status and need for care ongoing for injuries sustained in a motor vehicle accident, which occurred on 09/02/12 for which she received injuries to her neck and lower back. She does note continuing to improve with care. Her low back is coming along quicker than her neck. She does have continued complaints of neck pain with periods of numbness and tingling which radiate into her left upper extremity into her digits. She does have difficulty performing some of her activities of daily living due to the upper extremity pain. She does wake sometimes with pain which persists throughout the night on a sporadic nature. Working in a hair dressing capacity also tends to increase her pain and aggravates her current condition. Leslie notes that her pain scale today is a 3/10 on the Verbal Borg Scale in the neck and a 2-3/10 in the lower back. Cervical ranges of motion were restricted with left lateral flexion with a 20% loss, extension with a 10% loss and flexion with a 10% loss with general pain noted in the lower left side of the C spine and into the left trapezius muscle. Orthopedic testing remains positive for left Jackson compression with pain that radiates mildly into the upper extremity with an "electric type sensation" into her two middle fingers. Soto -Hall test was also positive for increased pain in the left trapezius muscle. Straight leg raise is negative in the lower back. She does have some mild lower lumbar spinal pain with Gilman's test at the L5 level local. Neurologically, she is intact in the lower extremities with normal DTRs. She does have some mild weakness secondary to pain in abduction of the right shoulder. DTRs in the upper extremities are within normal limits. Blood pressure today was tested at 120/70, seated on the left side. Chiropractic Palpatory findings reveal fixation/vertebral subluxation complex as noted in her SOAP note. She does have reduced fixation in the lumbar spine today. Elevated muscle tonicity of the left paraspinal musculature in the cervical spine with a +1-2 and into the trapezius muscle throughout with muscle trigger points and a general tone of +2. She has increased pain to isometric resistance with left rotation and left lateral flexion which reproduced increased pain in the left cervical spinal area local. No increased radicular pain was noted with this. THE HETRICK CENTER Leslie Glazer February 11, 2013 TREATMENT PLAN Page 2 of 2 The patient was treated today with electric muscle stimulation, heat, and manual traction and the appropriate specific adjustment to fixation levels in an effort to continue improving biomechnical motion. The patient will continue care at one time per week for the next 3 weeks, followed by reeval to determine her status and need for future care. It is my professional opinion with a reasonable degree of chiropractic certainty that the subjective complaints of my examination findings do continue to coincide with the automobile accident which occurred on 09/02/12. Continued care is medically necessary and appropriate. Continued goals would be to reach maximum medical improvement post accident status. I am anticipating some residual effects to the neck and upper back. She has had a recent EMG and is following up with her orthopedic su geon for a consultation. The patient will followup in approximately 1 week. She will cont ue to ice, increase water intake and avoid lifting, pushing, pulling or any other aggravating . ctors. Edward EL evner, D.C. DR Bush PENN REHABILITATION ASSOCIATES, P.C. ED S. V101AG0, M,0„ FAAPMR MACIEJ T. CHARCZUK, M.D.. FAAPMR Name: Fax:717756178388 Oct 28 2014 02:28am„ P009/018 Maximizing Function' Restoring Quality of Life Page 1 Physical Medicine • Rehabilitation * Electrodiagnosis ` Pain Management + /ME ' IRE ELECTRONEUROPHYSIOLOGICAL MEDICAL CONSULTATION ESLIE LOPER-GLAZER 5oclal Securir Date of Birth: Telepho dress; R Y: ror- Date: 02/19/2013 07/1 g&0 Sex; OfRce: 20 WEST SHADY LANE ENOLA PA 17025 R.1NILl,IAM BUSH Brief History: Female Harrisbu This is a 32 year old female complaining of neck pain to both upper extremities, Left more than the Right, with numbness and tingling since a MVA in Sept, 2012. 1. Needle EMG of both upper extremities from CS -T1 nerve roots revealed silence at rest, normal motor units, and complete Interference pattern during maximum effort. Interpretation: 2. Normal bilateral Median motor and sensory peak latencies. The sensory latencies were compared wiht the Ulnar and Radial nerves on the same side. 3. Normal bilateral Ulnar motor and sensory nerve conduction studies. 1. There Is no evidence of cervical radiculopathy from C6 T1 nerve roots bilaterally. Conclusion: 2. There Is no evidence of Carpal Tunnel Syndrome bilaterally. 3. There Is no evidence of plexopathy or myopathy. Thank you for the referral of your patient. If you have any further questions, please feel free to call me at the office. Ed Violago MD c5 114 p -0 -ll arm 10 ‘44-1-1 Transcribed by: of-i(v *27/2 This test was deemed medically necessary by the referring physician. CC: Tel: (717) MAIN OFFICE CARLISLE OFFICE HARRISBURG OFFICE 1 Ounwoody Drive 2151 Lingelotown Ra., Ceruse, PA 17015 Suite 240 Harrisburg, PA 17110 541-0700 Fax: (717) HALIFAX OFFICE 96 S. Rha Road & Rt 147 Halifax, PA 17a32 541-5100 NEWPORT OFFICE 46 Red Hill Ct. Newport, PA 17074 LEMOYNE OFFICE 550 North 1201 St, Lemoyne, PA 17043 FNA DR Bush ,4x.;-.11.7.756178388_ Oct 28 2014 02:281,a10/(0,u0 PENN REHABILITATION ASSOCIATES, P.C. ET LOPER-GLAZER,LESLIE Nerve R. Ulnar DATE 02/18/2013 I PAGE:1 1 MOTOR NERVE CONDUCTION STUDIES UPPER EXTREMITY Latency otor Nerve Conduction Amp Velocity Segment ms Sig mV m/s Sig Distance L. Ulnar R. Median Elbow - Wrist 2.5 Elbow - Weis Z.2 N 63 64 N 23.5 L. Median Ibow - Wrist 2. Elbow - Wrist L9 N R. Ulnar Across Elbow 62 N 69 N 24.5 Ulnar Across Elbow R. Radial L. Radial Forearm Forearm R. Radia Aoross Spiral Groove Radia Across Spiral Groove Other Other Other Other DR Bush _.Fax :?11-561-8389 Oct 28 201a 02:28pm .Z011 /018 f n� PENN REHABILITATION ASSOCIATES, P.C. NAME OPER-GLAZER,LESL,IE DATE 0219812013 PAGE:2 SENSORY NERVE CONDUCTION STUDIES UPPER EXTREMITY Nerve Segment Sensory Nerve Conduction Latency ms Sig R. Ulnar Wrist - V 2.8 L. Ulnar Wrist - V 3.0 Amp uV Sig 76 60 R. Median Wrist - II 2.8 Median Wrist - II 2,6 Radial Forearm - I 2.8 L. Radial Forearm - I 3. Other Other Other 60 N 45 18 N 14 DR Bush _. Fax;11.1-561-8388„ Oct 28 2014 02:28pm.„11012/018 PENN REHABILITATION ASSOCIATES, PC NAME I LOP ER-GLAZER,LESLIE DATE 0211 NEEDLE ELECTROMYOGROPHY RIGHT UPPER EXTREMITY Muscle (Root) homboid PA E:3 Fibs Pos Fasc HFD Polys MUP 'Wave Recr. Inter- erence Supraspinatus C5 Infraspinatus C5 Deltoid C5 eas C5-8 chioradialls C 6 Pronator Teres C6 Flex Carpi Radial CO 0 0 0 ex Carpi Ulnar C9 -T1 Extensor Olgltorum C7 Triceps C7 Flexor Pol Long C8 -T1 D 0 0 Ab Pol Brevis CO -T1 Ab Dig Min CO -T st Dorsal Int C8 T1 Paraspinals. C5-C6 C6-C7 C8 -T1 N Normal PW Positive Sharp Waves IIA Increased Insertional 40 None FAS Fasciculation Activity • Minimum GRD Complex Repetitive 3 SIngie Recrultltlent v+ Moderate Discharge P Partial Recruitment +++ Max PP Polyphasic Potentials F Full Recruitment I Increase LPP Long Duration rD Increased Duration D Decrease Polyphsalc Potentials Fibs Fibrillations SPP Short Duration X No Response DR Bush Fax:717-561-8388 PENN REHABILITATION ASSOCIATES, PC I NAME–T—LOR,-GI.AZER,LESLIE Muscle (Root) Rhomboid Supraspinatus C5 Infraspinatus C5 Deltoid CS Biceps C5-6 NEEDLE ELECTROMYOGRAPHY LEFT UPPER EXTREMITY Oct 28 201d 02:29pm. P013/018 13 { PAGE711 Recr_- Fibs Poe Fasc HFD Polys MUP Inter- ference nterference Wave 0 0 N N F Brachioradialls CS -6 a O 0 0 N N F Pronator Teres C6 Flex Carpi Radial CS O 0 0 N N Flex Carp1 Ulnar CB -Ti Extensor DIgltorunl C7 O 0 0 N N F 0 0 0 0 N N Triceps Cl 0 0 0 0 N N F Flexor Pol Long CS -T1 Ab Pol Bravls CB -T1 Ab Dig Min C8 T1 0 0 0 0 N N F 1st Dorsal Int C8 TI Paraspinals: C5-C6 C6-C7 N 40 f4 +4+ D Fibs CS -T1 Normal None Minimum Moderate Max increase Decrease Fibrillations PW FAS CRD PP LPP SPP Positive Sharp Waves IIA Fasciculation Complex RepatlElve S Discharge P Polyphasic Potentials F Long Duration 10 Polyphasic Potanttata Short Duration X Increased Insertional Activity Single Recruitment Partial Reorultmsnt Full Recruitment Increased Duration No Response LPECIAL NOTATION: The Hetrick Centers CHIROPRACTOR SOAP NOTE T,Id: 25-1640289 DATE: °` '1' ,}; i 3 1300 Bent Creek Boulevard Mechanicsburg, PA 17050 717-796-2225 20 North Barbara Street Mount Joy, PA 17552 717-492-0303 500 North Union Street Middletown, PA 17057 717-944-2225 845 Sir Thomas Court Suite 11A, Harrisburg, PA 17109 717-6524002 Last Name: S: Recurrent Acute 'Sub -acute First Name: MI: D.O.B:� -1 rbation Chronic New mplaint Wel DATE 0 ONS . VAS ' ain Scale 1 2 3®5 6 7 8 9 10 See DT. 5.1 �, tie" . A ./171 ' t• 1111‘76` —C . e 2114 4- "? VVV See DT. Osseous Findings & Osseous Treatment (Manipulation) C T I�j3 a45 7 8 9 X11 12 L 1 2 3 4 5 PR L B SR L B BP Extraspinal: • • • • S E T F TT -13 f ANT FSE P G F/D FSE P G SOT FSE P G FSE P H D TH A D TH A D TH A D TH A D TH A D TH A Soft Tissue Findings & Non -Osseous Treatment : Tenderness/1 2a 4 C T L EXTR / Tonicity 1 2(01 5 CP SO S-A / S -M / S -P LS SCM CEE / T -M / T-L<bL) E)2)' SP FR TP R SA T -MA / T -MI SUB SS IS P -MA / P -MI W -F / W -E (R / L) E TP (1 2) P SP FR LP QL LD P G —MAX / G—MED / G—MIN TFL BTHQ GAS PF (R I L) E TP (1 2) P SP FR OTHER: E TP (1 2) P SP FR Min. Manual TXN Time: Q5 Min. 1/A A/R M/R DMM PNF Time: Other: IFC RS SB PRE : t Min (Patient Tolerance) I -I 80-150 1-120 10-10 10-50. USP USC • Mm @ Watts./ CM 2 20/5% 40/10% 60/15% 80/20% 100/25% maCOLD t 5—Min Skin Conditio-Normal -Normal Today's Treatment: Well Tolerated N POST TX VAS. o Case Management Towards Resolution / Stability of Patient's Condition: RED FLAG: Yes No The patient's current complaint, past medical history, prior surgeries, medications, allergies, family history, social history and review of systems are all well outlined in the patient's medical record and these were reviewed today. New TX Plan Cont. TX Plan Modify TX Plan: ❑❑❑❑❑❑❑❑❑ Anticipated Treatment Plan: Days Weeks / Visit # New Exercise Program Min. (See handout): of RE Nutritional Support: ❑ Home Instructions: Taping / Strapping: Min Type of Tape Used: Body Region DME / Supports / Appliances: Studies: Rationale: Refer for outside services: Rationale: All exam information entered in ASHN Ix. plan (See ASHN form) Highmark tx. plan (See HM form) Other: Consulted with the patient on the following: Ii' emove _._.. I acto.. / Alter Ergonomics @ Work/ Home / Lifestyle Modification / Rest Y N / IHEP I Sleep Positions / Nutritional Counseling Val ICE / Contrast/ RICE / Smoking Cessation Goals: j. OAT Scores/Symptoms by 30 —50% by next evaluation/ Other: DIAGNOS W: Today's Notes: Signature: Bartako DC ODavid Carbo DC 0 Mary Colman DC 0 Scott Colman DC 0 Timothy Duke DC 0 Paul Hetrick DC Edward evner DC 0 Charlene Hobbie DC 0 Ashley Viele DC ■ 1 Add: Omit: Dictated Note Discharge Dictated OAT Highmark / ASHN TX &Progress Note ACN form D.C. LS‘PEC NOTATION: CHIROP DATE: 1. Last Name: S: Recur Hetrick Centers C OR SOAP NO Id: ' 5-1640289 Acute 300 Beau Creek Boulevard Meehanresburg, PA 17050 717- 20 Nor h Barbara Sweet Mount Joy, PA 17552 717-492-0303 00 Nor h Union Street Middletown, PA 17057 717-944-2225 5 Sir Thomas Court S First Name: 11A, Harrisburg, PA 17109 717-652-4002 Exacerbation Chronic New 1jP,Y�I CI r I . A— f1.,r I: D.O.B: plaint Wellness DATE OF ONSET: VAS Pain Scale 12 3 4 5 6 7 8 9 10 See DT. 0: See DT. Osseous Findings & Osseous Treatment (Manipulation C 0 1 2 3 4 7 T 1 t 3 40 7 8 9 10 11 12 L 1 2 3 4C P R L B SR . L B BP Extraspinal r 2 _- f'( I,. E F SE P S_E P G G G H TFat• D ANT D D SOT D D D TH A A A TH A TH A TH A Soft Tissue Findings & Non -Osseous Treatment : Tende CP SO i S-A / S -M / S -P LS SCM TP R SA T -MA / T -MI SUB SS IS P -MA / P -MI LP QL ILD P G —MAX / G—MED / G—MIN TFL B T OTHER: i 4 C T L EXTR / Tonicity gel 5 T -M / T -L ( L) E ® (2 )01 SP FR W -F / W -E (R / L) E TP (1 2) P SP FR H Q GAS PF (R / L) E TP (1 2) P SP FR E TP (1 2) P SP FR VA A/R M/R DMM PNF Time: Min. Manual t) TXN Time: () Min. Other. 1FC HV RS SB PRE : /5" -- USC Min COLD t � Min Skin Condition USP Min (Patient Toleemce)1-l0‘..---1-/0)8 0.150 1-120 10-10 10-50 Watts /CM 2 20/5% 40/10% 60/15% 80/20% 100/25% Today's T ell Tolerat N POST TX VAS 7 Case Management Towards Resolution / Stability of Patient's Condition: RED FLAG: Yes No Thelpatient's current complaint, past medical history, prior surgeries, medications, allergies, family history, social history and review of systems are ill well outlined in the patient's medical record and these were reviewed today. New +X Planont. TX Pla Modify TX Plan: End ❑ Anticipated Treatment Plan: Daysa___ Weeks / Visit # of ❑ New Exercise Program — Min. (See handout): ❑ Nutritional Support: 0 Home Instructions: ❑ Taping / Strapping: Min Type of Tape Used: Body Region ❑ DME 1,. Supports / Appliances: ❑ Studies: i ❑ Refer for outside services: Rationale: ❑ All exam information entered in ASHN tx. plan (See ASHN form) Highmark tx. plan (See HM form) ❑ Other: ; PRN MAR 04 2013 Rationale: Consulted with the patient on the following: Limit/Remove Aggravating =rs / Alter Ergonomics @ Work/ Home / Lifestyle Modification /;Rest Y N / IHEP / Sleep ' ositions / Nutritional Counseling / H .-. ' Contrast/ RICE / Smoking Cessation Goals: j OAT Scores/Symptoms by 3 0% by next evaluation/ Other: DIAGN Today's No Signature: is Add: Note Discharge Dictated OAT Highmark / ASHN TX &Progress Note ACN form D.C. ❑ E<l BartakoVits DC IP*, vid Carbo DC 0 Mary Colman DC 0 Scott Colman DC 0 Timothy Duke DC 0 Paul Hetrick DC 0 ward Hevner DC 0 Charlene Hobbie DC 0 Ashley Viele DC VCot 9 1; 4tA, r. 1 b i 4k ori 4- NL5 .-- 4" 'L . SX /k The Retrick Center Please Read: This questio ability to manage your We realize that you may WHICH MOST CLOSELY D • { a ..I a' .� VISED OSWESTRY CHRONIC LOW BACK PAIN DISABILITY QUESTIONNAIRE is designed to enable us to understand how much your low back pain has affected your activities. Please answer each section by circling the one choice that most applies to you. more than one statement may relate to you, but PLEASE JUST CIRCLE THE ONE CHOICE « I: �- YOUR PROBLEM RIGHT NOW. ON 1— Pain hneosity The pain comes end goes and is The pain is mild and does not C. The pain Domes and goes is D. The pain is moderate and does E. The pain Domes and goes and is F. The pain is severe and does not TION 2 — Personal Care I would not have to change my to avoid pain. I do not normally change my w though it causes some pain. Washing and dressing increases change my way of doing it. Washing and dressing increases change my way of doing it. E. Beaune of the pain, I am unabl without help. §ecanse of the pain, I am unab without help. B. F. C. D. N — a g ift heavy weights with can lift heavy weights, but i Pain prevents me from lifting Pain prevents me from lifting but I can manage if they are on a table. Pain prevents me from lifting age light to medium weights tinned. 1 can only lift very light wei CTION 4 Walking Pain does not prevent me • Pain prevents me from C. Pain prevents me from we D. E. F. 1I mild. much. vary um& much. y of washing or dressing of washing or dressing even e pain, but I manage not to pain and I find it necessary to o do some malting and dressing do any washing or dressing pain. causes extra pain. weights off the floor. vy weights off the floor, 'ently positioned, e.g., lo envy weights, but I can man - they are conveniently posi- J ♦ 4 Pain prevents me from I can only walk while using a I am in bed most of the time 5 —Sitting it in any chair as long B. 1 can only sit in my favorite C. Pain prevents me from sitting D. Pain prevents me from sitting E. Pain prevents me from sitting F. Pain prevents me from sitting atient's Signature 1. at the most. walking any distance. more than one mile. more than 1/2 mile. ninnies than 114 mile. or on crutches. have to crawl to the toil I like without pain. as long as I bice. than one hour. than 1/2 hour. than ten minutes. It B. C. D. E. F. C. D. E. F. ON 6 — Starting I can stand as long as I want without pain. I have some pain while standing. but it does not increase with ti,: I cannot stand for longer than one hour without increasing pain. I cannot stand for longer than 1t2 hour without increasing pain. I cannot stand for longer than ten minutes without increasing pail I avoid standing because it increases the pain straight away. ON 7 — Sleeping get no pain in bed. I get pain in bed, but it does not prevent me from sleeping well. Because of pain, my normal night's sleep is reduced by less than Because of pain, my normal night's sleep is reduced by less than Because of pain, my normal night's sleep is reduced by less than Pain prevents me from sleeping at all. I — Social Life M social life is normal and gives me no pain. My social life is normal, but increases the degree of my pain. C. Pain has no significant effect on my social life apart from limiti my more energetic interests, e.g., dancing, etc. Pain has restricted my social life and I do not go out very often. Pain has restricted my social life to my home. I have hardly any sociallife because of the pain. D. E. F. 0 y SECTION 9 — Traveling I get no pain while traveling get some pain while traveling, but none of my usual forms of travel make it any worse. C, I get extra pain while traveling, but it does not compel me to seek alternative forms of traveL D. I get extra pain while traveling, which compels me to seek alterna- tive forms of travel • Pain restricts all forms of travel Pain prevents all forms of travel except that done lying down. E. F. D. E. F. �1k 1 N 0 — Changing Degree of Pain MY My Dain is rapidly getting better. My pain fluctuates, but overall is definitely getting better. My pain seems to be getting better, but improvement is slow at present My pain is neither getting better nor worse. My pain is gradually worsening.� Mypfrmp�y� Date Score: From: K Hudson. L Tome -Nicholson, • tlw.—....o.. e Hetrick Center NECK PAIN DISABILITY QUESTIONNAIRE Please Read: This questionnaire is designed to enable us to understand how nluch your neck pain has affected your ability to manage your everyday activities. Please answer each section by circling the one choice that most applies to you. We real- ize that you may feel that more than one statement may relate toyou, but PLEASE NST CIRCLE THE ONE CHOICE WHICH MOST CLOSELY DESCRIBES YOUR PROBLEM RIGHT NOW. SECTION 1— Pain Intensity I have no pain at the moment B. The pain is very mild at the moment. . The pain is moderate at the moment D. The pain is fairly severe at the moment. E. The pain is very severe at the moment F. The pain is the worst imaginable at the moment A.CTION 2 — Personal Care I can look after myself normally without causing extra pain B. I can look after myself normally, but it causes extra pain. C. It is painful to look after myself and I am slow and careful. I need some help, but manage most of my personal care. I need help every day in most aspects of self-care. I do not get dressed, I wash with; difficulty and stay in bed. StCTION 3'— Lifting ' I can lift heavy weights without extra pain. B. I can lift heavy weights, but it causes extra pain. . Pain prevents me frori lifting heavy weights off the floor, but I can manage if they are, conveniently positioned, e.g:, onatable. .'.- ' :: D. Pain prevents me from lifting heavy weights off the floor, but I can manage light to medium weights if they are con- veniently positioned:.. E. I can lift very light weights. ' F. I cannot lift or carry anything at all. ';TION 4 —Reading ',can read as much as I.want to with no pain in my neck. f can read as much asi'want to with slight pain in my neck. (6.1 i can read as much as Fwant with moderate painin my neck. . . .: D. 1 cannot read as muclras I want because of moderate:pain:in my neck:. : ; : , I cannot read as much las I want because of severe pain in my neck: I cannot read at all, E. F. SECTION 5 -Headaches • ' k. I have no headaches at all. have slight headaches, which come infrequently. • have moderate headaches, which come infrequently. I have Moderate headaches, which come frequently. 's. I have severe headectes,'whic'h come frequently. • r. I have headaches almost all of the tune. Tent's Signatur SECTION 6 — Concentration I can concentrate fully when I want to with no difficulty. I can concenhate fully when I want to with slight difficulty. have a fair degree of difficulty in concentrating when I want to. Ihave a lot of difficulty in concentrating when I want to. I have a great deal of difficulty in concentrating when I want to. I cannot concentrate at all. D. E. F. SECTION 7 — Work I can do as much work as I want to. I can only do my usual work, but no more. C. I can do most of my usual work, but no more. D. I cannot do my usual work. B. I can hardly do any work at all. F. I.cannot do any work at all. SECTION 8 —Driving A. I can drive any car without any neck pain. I can drive my car as long as I want with slight pain in my neck. I can drive my car as long as I want with moderate pain in my neck. D.• I:cannot drive my car as long as I want because of moderate pain in my, neck. E. I can hardly drive at all because of severe pain in my neck. F. I cannot drive my car at all, SECTION 9— Sleepina I have no trouble sleeping. y sleep is slightly disturbed (less than 1 hour sleepless). :y sleep is mildly disturbed (1-2 hours sleepless). .My: sleepis moderately disturbed (2-3 hours sleepless). My sleep is greatly disturbed (3-5 hours sleepless). My sleep is completely disturbed (5-7 hours sleepless). SECTION 10 — Recreation A. I am able to engage in all of my recreational activities, with no neck pain at itiT . I am'able to engage in all 'of my rew rational activities, with some pain m my.neck. C. I am able to engage in most, but not all of my usual recreational activities because of pain in my neck. 11 I am able to engage in a few of my usual recreational activities be- cause ofpaihin my neck. I' can; hardly. do any recreational activities because of pain in my neck. I cannot do any recreational activities at all. Score: Date` After Vernon & Mar. 1992 Reprinted by permission of the Journal of • Manipulative end Physiological Therapeutics THE HETRICK CENTER You have a choice for Physical Therapy...c hoose us! 500 North Union Street 1300 Bent Creek Boulevard 20 North Barbara Street 845 Sir Thomas Court, Suite 11A Middletown, PA 17057 Mechanicsburg, PA 17050 Mount Joy, PA 17552 Harrisburg, PA 17109 Office: (717) 944-2225 Office: (717) 796-2225 Office: (717) 492-0303 Office: (717) 652-4002 Fax: (717) 944-0932 Fax: (717) 796-2229 Fax: (717) 492-0309 Fax: (717) 652-4005 April 10, 2013 Harrisburg RE: Glazer, Leslie DOB: 03/07/1980 PI CLINICAL HISTORY Ms. Glazer presents back to The Hetrick Center today for a reevaluation. She has been incredibly busy with full time work and full time student as a nursing student. She has had great difficulty maintaining her recommended frequency. Last seen by myself, on 03/04/13. She does note having little to no pain in the lower back today. Neck pain is mild. She notes a 2-3/10 pain on the Verbal Borg Scale. She does have some residualrestriction in cervical range of motion with left lateral flexion and left rotation. She still experiences upper extremity radiating pain and paresthesias into the fingertips on the left side, but notes this at a reduced frequency, more prominent after more physical activity or sleeping for which she notes increased pain with a supine or left side lying position. She has been compliant with her independent home exercise program but does have some difficulties continuing icing due to a rather busy schedule. Cervical ranges of motion today were restricted with left lateral flexion with a 10% loss and left lateral rotation with a 10% loss. She has mild increased pain with left Jackson compression which is local into the lower cervical pain. No radicular pain was noted with this. Neurologically she is intact in the upper extremities. She does have persistent trigger points and elevated muscle tone, particularly in the left trapezius muscle. They are +1-2. Multiple trigger points are also tender to light pressure with a +3 response. Chiropractic Palpatory findings reveal gross fixation/vertebral subluxation complexes as noted in her SOAP notes. , She does have mild tenderness over the spinous process of L5 today. Lumbar range of motions were full. Orthopedic testing was negative for straight leg raise b/1 for lower back pain. TREATMENT PLAN The patient was treated today with the appropriate specific adjustments, electrical stimulation and heat. The patient was able to tolerate them very well, noting feeling quite well post-treatment. The patient is hereby discharged, having reached maximum medical improvement with some THE HETRICK CENTER Glazer, Leslie April 10, 2013 Page 2 of 2 residual pain in the neck and sporadic radicular pain to the left upper extremity. She is continuing to follow-up with her orthopedic surgeon for further care. It is my professional opinion within a reasonable degree of chiropractic certainty that the patient has reached maximum medical improvement with some residual effects to her neck and upper extremity on the left side as noted. The patient will continue to do independent home exercise program, icing, and avoiding lifting, pushing, pulling or other aggravating factors that may increase her pain. I did advise the patient to contact our office if pain significantly increases. Please see other . tations, etc. for further details surrounding her health history and motor vehicle accident • -tails. Edward Hevner, D.C. EL THE HETRICK CENTER Glazer, Leslie April 10, 2013 Page 2 of 2 residual pain in the neck and sporadic radicular pain to the left upper extremity. She is continuing to follow-up with her orthopedic surgeon for further care. It is my professional opinion within a reasonable degree of chiropractic certainty that the patient has reached maximum medical improvement with some residual effects to her neck and upper extremity on the left side as noted. The patient will continue to do independent home exercise program, icing, and avoiding lifting, pushing, pulling or other aggravating factors that may increase her pain. I did advise the patient to contact our office if pain significantly increases. Please see other . tations, etc. for further details surrounding her health history and motor vehicle accident • -tails. - Lam.. Edward Hevner, D.C. EL ' SPECIAL NOTATION: The Hetrick Centers CHIROPRACTOR SOAP NOTE Tax Id: 25-1640289 DATE: L • ((9 ` 1 3 1300 Bent Creek Boulevard Mechanicsburg, PA 17050 717-796-2225 20 North Barbara Street Mount Joy, PA 17552 717-492-0303 500 North Union Street Middletown, PA 17057 717-944-2225 845 Sir Thomas Court Suite 11A, Harrisburg, PA 17109 717-652-4002 Last Name: G Lek 2 e., First Name: /A..5 / e MI: D.O.B: - 6r0 S: Recurrent Acute Sub -acute Exacerbation Chronic New complaint Wellness DATE OF ONSET: Avg. Pain over 2 weeks (0 —10) (3 ) Pain Affecting ADL's (0-10 O: See D1j Osseous Findings & Osseous Treatment (Manipulation) C 0 1 2 3 4©6 7 T 1®35 6 7 8 9 10 11® L 1 . 3 Cd P R L B S R L B BP Extraspinal: F�E F E P • F -3)E G • FSE P G • FSE:P G • FSE P H 9.; SOT D TH A D TH A D A D TH A D TH A D TH A Soft Tissue Findings & Non -Osseous Treatment : Tenderness 3 4 C T L EXTR / TonicitD 3 4 5 L 4.§0 S-A / S -M / S -P LS SCM / T -M / T -L 4) E TP (1 2) P SP FR TP R SA T -MA / T -MI -SUB SS IS P -MA / P -MI W -F / W -E (R / L) E TP (1 2) P SP FR LP QL LD P G —MAX / G—MED / G—MIN TFL BTHQ GAS PF (R / L) E TP (1 2) P SP FR OTHER: E TP (1 2) P SP FR I/A A/R M/R DMM PNF Time: _ __ _ Min. Manual C _TXN Time• 63t Min. Other: IFC (2) RS SB PRE : [ Sr" Min (Patient Tolerance) 1-1 8012 80-150 1-120 10-10 10-50 USP USC Min @ Watts / CM 2 20/5% 40/10% 60/15% 80/20% 100/25% HO COLD [ S Min Skin Condition :G4s-Normal ` ost-Normal /') Today's Treatment: Well Tolerate N POST TX VAS ❑ Case Management Towards Resolution / Stability of Patient's Condition: RED FLAG: Yes No The patient's current complaint, past medical history, prior surgeries, medications, allergies, family history, social history and review of systems are all well outlined in the patient's medical record and these were reviewed today. New TX Plan Cont. TX Plan , Modify TX Plan: Anticipated Treatment Plan: Days Weeks / Visit # of Re-eval.Date: ❑ Exercise Program ❑ Nutritional Support: ❑ Home Instructions: ❑ Taping / Strapping: Min Type of Tape Used: Min. (See handout): i ❑ DME / Supports / Appliances: aStudies: RationalxpR 0 2013 Refer for outside services: Rationale: ❑ All exam information entered in ASHN tx. plan (See ASHN form) Highmark tx. plan (See HMfor»i) ❑ Other: RECORDS SEW( Region Consulted with the patien the following: Limit/Remove Aggravating F rs / Alter. Ergonomics @ Work/ Home / Lifestyle Modification / Rest Y NULIEP. Sleep Positions / Nutritional Counseling / Heat Contrast/ RICE / Smoking Cessation Goals: 1 OAT Scores/Symptoms by 30 —50% by next evaluation/ Other: DIAGNOSIS: Today's Notes: Signature: Add: Omit: Dictated Not 'sc are Dictate Highmark / ASHN TX &Progress Note ACN form D.C. ❑ i;d Bartakovits %C ODavid Carbo DC ❑ Mary Colman DC 0 Scott Colman DC 0 Timothy Duke DC 0 Paul Hetrick DC Edward Hevner DC 0 Charlene Hobbie DC 0 Ashley Viele DC 0 Jason Green DC 441/141(2. usai , P - q 22 6 lc 06 ft if' 2w41k4 — c.t,15 ltsiCuAnn P- c Zta'a Peso/ Va,-- to V tc44. VAS -91317rl2•ete, LTA �Vrlliabus _ ii- 3 o 13 pt Ay .i.e 0- t e"-K-; .-,a Y cam; u-, } o .. DR Bush Fax:717-561-8388 Oct 28 2014 02:28pm P001/019 Patient's Name Date • Age • S.Mt CHIEF COMPS i11NT = Chief co ADDITIONAL HISTORY: PHYSICAL FINDINGS •M601CAT1ON3 :be. -; . %� =la' x{!,j+► •� .. fs= si %:s:;' -F • , ..... _... •. Uisteryy-at Ij preav>st ilttt Al c Gcd .j Review If • syst_oms: th.e t,.tta,w;.g •� • %e+..-.ctix..ed. •eyes, Eh Ide ell , - , r, T,. cardiovascul''- ar, respirato sstroia �: nal . �c • peyc o r ., 70 . '1 +hour» , e ` , in no scute distress. litt.N is normal, Optic media are clear, the tragus, external canal, t m • ani es are norma ; t e pharynx, hard The teeth acre in ?And repair. _, nd'soit palate sfre,• • . 'N k: :Neck 1 t . is supple without thyoroidmegaty or JVD. Normal tra •• eal ._ ' ,. gs: C1ear to auscultation and .percussion. Normal res r irato _ . E DOSIS. *J heart egular rhythm, —�' hyt , n ormal Si, S2, no murmurs. No cardiome sly ' '.>.: Periph ral vascular: ascular; „ . , norma. - n • • istcultun or masses. No ascites. No evidence of herias..The umbilic tt� s r i Bowel sounds ,.. , 1 ega _.. , ere ..cis: •`; '. Extre ities: There is full range of mntinn Th... no noted N° erythrema.. • _ 's sign is negative. No Varicosities. x'YmP atics: Negative survey of Flash meek, Clci.l axilia,.g. eta b;lateraily, • • 10eion 10 , e o ee mg oreccymosis. Normal cc or. fait/ _I'd . Neurological: Pup Ari, Pqua1 no abnormal i1 and reoct.v., to light, the cranial ne reflexes, there are no focal defisits,Jbtgate is nor • es are intact, there a Rom re, �r'g'' �[ is • "— egatite. The patient Is alert and -oriented and all spheres. Aiagnosis: PL VYjj1i R B+�sh, A4.9. ! Name Date of birth General health DR Bush Fax:711-561-B3BB FAMit Y ANtLuNTFRNAL ME,D1OINE WILLIAMVSUSH MD 544 .116E414 -TER S - HARRISBURG, lovetIMYLVANIA 17111 (7_ 1 -4.1 'D Oct 28 201A 02:21pm POOA ADULT HEALTH HISTORY Oate Are you currently or have you ever been treated for • Yes No Condition Asthma Explain Gastro-intestinal problems Heart disease Kidne disease leamin disorders 1111111 UMP?* Menstrual problems OIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIMIIIIM Mlle Musculo -skeletal IMITRSIMENEMEIMMUNUMIll It- P chol ical/ s chiatric aler1- 11111 Ill nMAIIVMEATEIMIMIONMMMIMMMNIIIIMIIIIIIIIIIIIIIII.M.IMINIIil 111M111 Sickle cell disease 1111.1111.1111111111111111111111111111111.11 aMillial ,I all List all medications you are currently taking, include over-the-counter drugs and herbal Supplements www.FreePrintabieMedicalFonrns.com a 7 West Shore Campus 2005 Technology Parkway PINNACLEEALTH Suite 400Mechanicsburg, PA 17050 Phone: (717) 791-2520 Fax: (717) 703-0061 Neurosurgery and • Neurosciences. Institute CI •„Community Campus Bloom Outpatient Center 4310 Londonderry Road, Suite 202 Harrisburg, PA 17109 Phone: (717) 791-2520 Fax: (717) 920-4361 You have been referreq to aur office by your doctor, Dr. Qf T1 jOr i Dr. le 3 : Please arrive 15 minutes early.. -1f unable to keep this 1 , appointment: plea give our office greater than 24 hours notice. The insurance information we were Given is for an p pointment on t j at Date J to see If this is incorrectplease contact our office with correct information prior to your visit. • Enclosed you will find a map to our office. Also enclosed are two forms: A New Patient Registration Form and Medical History Questionnaire. Please complete these forms (multiple pages) as completely as possible and bring them with you to your appointment. Please pay particular attention to fisting your medications and dosage accurately. If you have hed a previous x-rayS, CT scans, or MRIs performed, please 'bring films/discs with you to Our appointment. Please bring your medical 'insurance cards and photo ID with you and any other information for billing your visits. If you have insurance that is an HMO or Point of Service requiring an authorization for your visit, bring along your referral informafiomand/or paperwork. If we do not have it, we may need to reschedule your appointment. If your insurance fiesta co=pay, yourare:responsible topay at time Of visit. We participate with most insurance plans, however, if you have alfinsurance;:that we do not participate with, you will be asked to pay' • .fior your visitat.ttie- e.•of service. We look forward to seeing you. If you have any questions please call our offic. Sincerely, The Staff at the PinnacleHealth Neurosurgery ai Neurosciences Institute Enciosures Form 1457-116 (10113) Int) Pi NNACLEHEALTH NEUROLOGICAL SURGERY Thank you for selecting our healthcare team! To help us meet your healthcare needs, please fill out this form completely. Please print and use black ink. Name 1-61(ei 611t0 Birth Date 317/160 Age 33 Dat • for witt sae spoil n IlAckicholeters- heilr a ttbz Patient Medical -History Have you ever had the following (check "no" or "yes" leave blank if uncertain): - Reason for visi Measles Mumps O No - O No Chickenpox 0 No Whooping Cough 0 No Scarlet Fever 0 No 0 Yes o Yes O Yes IZE Yes O Yes Venereal Disease 0 No Anemia 0 No Bladder Infections 0 No Epilepsy . 0 No Migraine Headaches 0 No Diphtheria;:,- No• D.Yes,Tuberculosis Smallpox 0 No 0 Yes Diabetes Pneumonia 0 No fa Yes Cancer Rheumatic Fever 0 No 0 Yes Polio Heart Disease .0 No 0 Yes Glaucoma Arthritis 0 No 0 Yes Hernia O Yes ki Yes Vt Yes O Yes Yes Blood or 0 No 0 Yes Persistent cough or throat clearing not Plasma Transfusions associated witha known illness (lasting more than 3 weeks) 0 No 0 Yes Back Trouble High or Low Blood Pressure O No fZ Yes O No .0 Yes Mitral Valve Prolapse 0 No 0 Yes. Stroke O No 0 Yes Hemorrhoids 0 No.0 Yes Hepatitis 0 No 0 -YeS:.:ificer O No 0 Yes Kidney Disease 0 i46 0 Yes ..'Asthiiie O No 0 Yes O No 0 Yes O No 0 Yes O No 0 Yes Previous Hospitalizations/Surgeries/Serious Illnesses 0 Continued on back if necessary o Single Diet (circle): /21 Married Regular Use of Tobacco: aCigarettes Hives or Eczema AIDS or HIV+ infectious Mono Bronchitis O No 0 Yes O No Z Yes O No Yes Date of last chest x-ray ThyroidDisease Bleeding Tendency Any Other Disease (please list) O No 0 Yes O No 0 Yes 0 :NcElayes O No 0 Yes O No 0 Yes O No 0 Yes O No 0 Yes When Hospital, City, State Patient Social History o Divorced o Widowed :10 Student Height Weight Diabetic - ADA calories Special packs/day o Cigar 0 Pipe 'o Quit/When NeVet, Occasionally :o Frequently : Please check if you have: o dentures 0 contact lens o pacemaker/defibrillator/stimulator/shunt/pump o hearing aids o eye/lens implants o metal of any type in your body Family History 0 artificial joints o artificial limbs • Form 1464-07 (02/09) InD Father Mother Brother Sitter Spouse, Partner Children 1 2 3 1 4 1 2 ..3 4 1 2 3 4 5 6 Age (if living) I 1 Health (G) good (B) bad Cancer Tuberculosis . Diabetes. Heart Trouble , High Blood Pressure .ke ..... Stro . Epilepsy. • ./. Age (at death) Cause of death Form 1464-07 (02/09) InD P KN LEHEAKTH Pinnacle Health Phygician Practice Network Payment Policy We welcome you as our patient and appreciate the opportunity to provide you with medical services. We are committed to providing you with quality and affordable health care. Because some of our patienthave had questions regarding patient and insurance responsibility for services rendered, we have developed this policy to assist you. Please read it, ask us any questions you may have, and sign in the space provided. A copy will be provided to y�u upon request. 1. Insurance. We participate in most insurance plans, including Medicare. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage. VVeanaahon-netvorkproviderfbrThCane and you may be billed forthe difference between what we charge and what TriCare pays. If you are not insured by a plan we do business with, we ask that you make payment in full at the time of service. We will courtesy bill for services over $100.00. We can provide you with a receipt for you to send to your insurance company for reimbursement 2. Co -payments and deductibles. All co -payments anddeductibles must be paid at the time of service. We accept cash, checks, MasterCard,Visa,D�covac�sweUasdeb�cords��p�ymenL 3. Non -covered services. Please be aware that some of the services you receive may be noncovered or not considered reasonable or necessary by Medicare or other insurers. You must pay for these services in full at the time of visit 4. Proof of insurance. All patients must complete our patienform before seeing the doctofor the first time. We must obtain a copy of your current valid insurance to provide proof of insurance. Each time you visit your doctor, you will be asked to show your insurance card. ---5:-Claims submission. We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Pleasbeaware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract. Your contract includes payment of co -pays and deductibles. G. Coverage changes. If your insurance changes, please notily us before your next visit so we can maKe appropriate changes to help you receive your maximum benefits. If your insurance company does not pay your claim in 90 days, the balance will automatically be billed to you. 7. Nonpayment. If your account is over 90 days past due, you will receive a notice stating payment in full must be received immediately to avoid further collection efforts. if you have any concerns regarding your account balance, • please contact the Professional Billing Office at 717-231-8960 or 1-800-565-6229. 8. Missed appointments. You may be charged for a missed appointment not canceled within 24 hours. These charges will be your responsibility and billed directly to you. Please help us to serve all patients better by keeping your regularly cheduled appointment. Our practice is committed to providing the bestreatment to our patients. Our prices are representative of the usuaand customary charges for our area. Please let us know if you have any questions or concerns. I have read and understand the payment policy and agree to abide by its guidelines. Y_ e,��L��carN of patien n le se print) Form 1531-153 (04/Dg) InD Date DR Bush Fax:711-561-8398 pp 28 2014 02;29pm P014 ` • Insurance GHIEf COMPLAINT , ^'ir CIue{ con i ADDJTIONAL HISTORY: PHYSICAL, FINDINGS • ;MEDICATIONS: , .... • ie'W' of i y_ NI; ,car, tic me(j ni•ar deaithe tca us *extern ,e Masa• tur. iiri'ntes' ace normnal;: t1 itx.. harts ant: soft : aiate'•are.. e to 'sets tat u:std- serc►t re TEtidik,C3t'igCgSseS. o 8seiters.'.•N o evtiLletlee; of. kiernis ' i`ia ' uYii#s.il' us rae ss no •posn ' sr{ ersiess oT rebound. There"is»o • a n.omeg '�romities:;,T4e iti.; F:\FILES\Clients\3050 Donegal\3050 Current \3050.722\3050.722.ansl.wpd Revised: 11/4/14 1:17PM Daniel K. Deardorff, Esquire MARTSON LAW OFFICES I.D. 17837 10 East High Street Carlisle, PA 17013 (717) 243-3341 Attorneys for Defendant ,ED -O Fft; 1 1HE PR01t90HO AF:, 2014 NOV -6 AM 8: 20 CUMBERLAND COUNTY PENNSYLVANIA CHAD GLAZER & LESLIE LOPER-GLAZER, Plaintiffs : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA v. : NO. 14-5082 : CIVIL ACTION - LAW CHARLES R. UHRICH, Defendant : JURY TRIAL DEMANDED DEFENDANT'S ANSWER WITH NEW MATTER TO: CHAD GLAZER AND LESLIE LOPER-GLAZER, Plaintiffs, and their attorney, PAUL BRADFORD ORR YOU ARE HEREBY NOTIFIED TO FILE A WRITTEN RESPONSE TO THE ENCLOSED NEW MATTER WITHIN TWENTY (20) DAYS FROM SERVICE HEREOF OR A JUDGMENT MAY BE ENTERED AGAINST YOU. AND NOW comes Defendant, Charles R. Ulrich, by and through his attorneys, MARTSON LAW OFFICES, and hereby responds to Plaintiffs' Complaint as follows: 1-3. Admitted based on information received. 4. Admitted. 5-6. Denied. After reasonable investigation, Defendant is without sufficient knowledge or information to admit or deny said averments. Proof is demanded. 7. It is denied that Defendant was the operator of a 2011 Chevrolet Malibu or any other vehicle at said time and place. Proof is demanded. 8. Denied. After reasonable investigation, Defendant is without sufficient knowledge or information to admit or deny said averments. Proof is demanded. 9. It is denied that Defendant was the operator of a 2011 Chevrolet Malibu or any other vehicle at said time and place. Proof is demanded. 10. The Answer to Paragraph 7 is incorporated herein by reference and made of part hereof It is denied that Defendant was negligent or careless at said time and place in that he was not operating a vehicle at that time and place. COUNT I 11. The Answers to Paragraphs 1 through 10 are incorporated herein. 12-14. Denied. After reasonable investigation, Defendant is without sufficient knowledge or information to admit or deny said averments. Proof is demanded. WHEREFORE, Defendant demands judgment in his favor and against Plaintiffs. COUNT II 15. The Answers to Paragraphs l lthrough 14 are incorporated herein. 16-21. Denied. After reasonable investigation, Defendant is without sufficient knowledge or information to admit or deny said averments. Proof is demanded. WHEREFORE, Defendant demands judgment in his favor and against Plaintiffs. NEW MATTER 22. Defendant was not the operator of any vehicle involved in the accident at the time and place referred to in Plaintiffs' Complaint. 23. Based on information received, Defendant believes Mary Uhrich was the driver. 24. These causes of action are barred by The Statute of Limitations. WHEREFORE, Defendant demands judgment in his favor and against Plaintiffs. MARTSON LAW OFFICES By Date: II \ (el (l� 41e - Daniel K. Deardorff, Esquire I.D. Number 17837 10 East High Street Carlisle, PA 17013 (717) 243-3341 Attorneys for Defendant VERIFICATION The foregoing Defendant's Answer with New Matter is based upon information which has been gathered by my counsel in the preparation of the lawsuit. The language of the document is that of counsel and not my own. I have read the document and to the extent that it is based upon information which I have given to my counsel, it is true and correct to the best of my knowledge, information and belief. To the extent that the content of the document is that of counsel, I have relied upon counsel in making this verification. This statement and verification are made subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities, which provides that if I make knowingly false averments, I may be subject to criminal penalties. F:\FILES\Clients\3050 Donegal\3050 Current \3050.722\3050.722.ans l .wpd arles R. Ulrich CERTIFICATE OF SERVICE I, Ami J. Thumma, an authorized agent of MARTSON LAW OFFICES, hereby certify that a copy of the foregoing Defendant's Answer with New Matter was served this date by depositing same in the Post Office at Carlisle, PA, first class mail, postage prepaid, addressed as follows: Paul B. Orr, Esquire 50 East High Street Carlisle, PA 17013 MARTS By Dated: (I 6, l `q • LAW : ICES 111111 Ami Thu en East Hi gfi Street Carlisle, PA 17013 (717) 243-3341