Chiropractic Evaluation Template

Complete chiropractic initial examination template with all required sections. Use this free template as a reference or let SOAP Note Buddy auto-fill your evaluations.

What is a Chiropractic Evaluation?

A chiropractic evaluation (also called an initial examination, intake, or new patient exam) is a comprehensive assessment performed by a Doctor of Chiropractic at the start of care. It establishes the patient's baseline condition, identifies vertebral subluxations and other neuromusculoskeletal dysfunction, determines the diagnosis and prognosis, and creates the treatment plan.

The chiropractic evaluation is the foundation of all subsequent care. It serves multiple critical purposes:

  • Diagnosis: Identifies subluxations, joint dysfunction, and related conditions requiring chiropractic care
  • Medical Necessity: Establishes why chiropractic manipulative treatment (CMT) is appropriate
  • Treatment Planning: Guides the type, frequency, and duration of care
  • Legal Documentation: Creates a record of the patient's condition at initial presentation
  • Insurance Compliance: Supports billing and meets Medicare/insurance documentation requirements
Medicare Documentation Requirements Medicare requires documentation of subluxation by X-ray or physical examination, including the specific spinal level, direction of misalignment, and clinical findings. Without proper subluxation documentation, CMT claims will be denied.

What Does a Chiropractic Evaluation Include?

A complete chiropractic evaluation follows a structured format that captures the patient's history, examination findings, subluxation analysis, and treatment plan. Each section builds on the previous to support your clinical decision-making.

1. Patient History

Comprehensive background including chief complaint, history of present illness (onset, location, duration, character, aggravating/relieving factors), past health history, family history, and review of systems. This establishes context for the patient's condition.

2. Physical Examination

Vital signs, postural analysis, range of motion testing (cervical, thoracic, lumbar), and palpation findings. Documents observable and measurable clinical findings that support diagnosis.

3. Orthopedic Testing

Condition-specific orthopedic tests to assess joint function, identify pathology, and rule out contraindications to manipulation. Tests are selected based on the patient's presenting complaint and examination findings.

4. Neurological Examination

Deep tendon reflexes, sensory testing, motor strength testing, and pathological reflexes as indicated. Essential for identifying nerve involvement and ruling out serious pathology.

5. Spinal Analysis and Subluxation Listings

Detailed documentation of vertebral subluxations using standard listing notation. Includes segment identification, direction of misalignment, associated soft tissue findings, and functional implications.

6. Diagnosis and Treatment Plan

ICD-10 diagnosis codes, treatment frequency and duration, specific interventions planned, goals of care, and patient education. This section establishes the roadmap for care.

Complete Chiropractic Evaluation Template

Below is a comprehensive chiropractic initial examination template. Use this as a reference for manual documentation or let SOAP Note Buddy auto-generate evaluations in your EHR.

Patient Information

Patient Name
[Patient Name]
Date of Birth
[DOB]
Date of Evaluation
[Date]
Referred By
[Self / Physician Name]
Insurance Information
[Insurance carrier, policy number, authorization if required]

Patient History

Chief Complaint
[Primary reason for seeking care. Include location, onset, duration, and how it affects daily activities. Document in patient's own words when possible.]
History of Present Illness
[Detailed history using OPQRST format: - Onset: When and how did symptoms begin? Gradual or sudden? Mechanism of injury? - Provocation/Palliation: What makes it worse? What provides relief? - Quality: Nature of pain (sharp, dull, aching, burning, radiating) - Region/Radiation: Exact location, does it radiate? - Severity: Pain scale 0-10, at rest, worst, current - Timing: Constant vs. intermittent, time of day, duration of episodes Include previous treatments and their effectiveness.]
Past Health History
[Previous injuries, surgeries, hospitalizations, chronic conditions. Include previous chiropractic care and response. Note any history of cancer, fractures, or inflammatory conditions.]
Current Medications
[List all medications, dosages, and frequency. Note pain medications, muscle relaxants, anti-inflammatories, blood thinners.]
Family History
[Relevant family medical history: arthritis, osteoporosis, spinal conditions, cancer, cardiovascular disease.]
Social History
[Occupation and work duties, physical activity level, smoking/alcohol use, sleep quality, stress level.]

Review of Systems

ROS Notes
[Document any positive findings or pertinent negatives]

Physical Examination

Vital Signs

Blood Pressure
[BP mmHg]
Pulse
[HR bpm]
Respiration
[RR/min]
Height/Weight
[Height, Weight, BMI]

Postural Analysis

Anterior View
[Head tilt, shoulder level, hip level, knee alignment, foot positioning]
Lateral View
[Forward head posture, cervical lordosis, thoracic kyphosis, lumbar lordosis, pelvic tilt]
Posterior View
[Scapular position, spinal alignment, PSIS levels, gluteal folds]

Range of Motion

Cervical ROM
[Document AROM with pain notation: - Flexion: ___/50 deg (pain: Y/N) - Extension: ___/60 deg (pain: Y/N) - Right Lateral Flexion: ___/45 deg (pain: Y/N) - Left Lateral Flexion: ___/45 deg (pain: Y/N) - Right Rotation: ___/80 deg (pain: Y/N) - Left Rotation: ___/80 deg (pain: Y/N)]
Thoracic/Lumbar ROM
[Document AROM with pain notation: - Flexion: ___/90 deg (pain: Y/N) - Extension: ___/30 deg (pain: Y/N) - Right Lateral Flexion: ___/30 deg (pain: Y/N) - Left Lateral Flexion: ___/30 deg (pain: Y/N) - Right Rotation: ___/30 deg (pain: Y/N) - Left Rotation: ___/30 deg (pain: Y/N)]

Palpation Findings

Cervical Spine
[Tenderness, muscle spasm, trigger points, segmental fixation/hypermobility. Identify specific levels.]
Thoracic Spine
[Tenderness, muscle spasm, rib involvement, segmental dysfunction]
Lumbar Spine
[Tenderness, paraspinal hypertonicity, segmental fixation, SI joint involvement]
Extremities (if applicable)
[Shoulder, hip, knee, or other joint findings as indicated]

Orthopedic Testing

Cervical Orthopedic Tests

[Document relevant tests with results (+/-): - Cervical Compression: R ___ L ___ - Cervical Distraction: ___ - Spurling's Test: R ___ L ___ - Shoulder Depression Test: R ___ L ___ - Valsalva Maneuver: ___ - Jackson's Test: R ___ L ___ - Soto-Hall Test: ___]

Lumbar/Sacroiliac Orthopedic Tests

[Document relevant tests with results (+/-): - Straight Leg Raise (SLR): R ___ deg L ___ deg - Braggard's Test: R ___ L ___ - Kemp's Test: R ___ L ___ - Patrick's/FABER Test: R ___ L ___ - Gaenslen's Test: R ___ L ___ - Yeoman's Test: R ___ L ___ - Hibb's Test: R ___ L ___ - Minor's Sign: ___ - Valsalva Maneuver: ___]

Additional Orthopedic Tests

[Any additional tests performed based on clinical presentation: shoulder, hip, knee tests as indicated]

Neurological Examination

Deep Tendon Reflexes

Biceps (C5)
R: ___ L: ___
Brachioradialis (C6)
R: ___ L: ___
Triceps (C7)
R: ___ L: ___
Patellar (L4)
R: ___ L: ___
Achilles (S1)
R: ___ L: ___

Grade: 0=Absent, 1+=Hyporeflexia, 2+=Normal, 3+=Hyperreflexia, 4+=Clonus

Sensory Examination

[Document dermatomal sensation testing. Note any areas of hypesthesia, hyperesthesia, or paresthesia. Include specific dermatomes tested and modality (light touch, pinprick).]

Motor Strength Testing

[Document myotomal strength (0-5 scale): - Shoulder Abduction (C5): R ___ L ___ - Elbow Flexion (C5-6): R ___ L ___ - Wrist Extension (C6): R ___ L ___ - Elbow Extension (C7): R ___ L ___ - Finger Flexion (C8): R ___ L ___ - Hip Flexion (L2): R ___ L ___ - Knee Extension (L3-4): R ___ L ___ - Ankle Dorsiflexion (L4-5): R ___ L ___ - Great Toe Extension (L5): R ___ L ___ - Ankle Plantarflexion (S1): R ___ L ___]

Pathological Reflexes

[Babinski sign, Hoffman's sign, clonus - document as present/absent. Note any upper motor neuron signs.]

Spinal Analysis and Subluxation Listings

Subluxation Documentation for Insurance Medicare and most insurers require specific documentation of subluxation including: (1) the spinal level, (2) evidence of dysfunction through physical examination or X-ray, (3) associated clinical findings, and (4) functional implications. Without this documentation, CMT claims may be denied.
Subluxation Listings
[Document each subluxation with standard listing notation: Segment | Listing | Associated Findings | Functional Impact --------|---------|---------------------|------------------ C5 | PRI | Hypertonicity right paraspinals, tenderness | Restricted right rotation, right arm numbness T4 | PL | Rib fixation, intercostal tenderness | Pain with deep breathing L4 | PRI-SP | Bilateral paraspinal spasm, positive Kemp's right | Antalgic posture, limited extension Include: - Direction of misalignment (P=Posterior, A=Anterior, R=Right, L=Left, I=Inferior, S=Superior) - Soft tissue involvement (hypertonicity, edema, tenderness) - Neurological implications if present - Functional limitations caused by subluxation]
X-Ray Findings (if taken)
[Document radiographic findings supporting subluxation: - Views taken - Alignment abnormalities - Degenerative changes - Anomalies - Mensuration findings (if applicable) - Contraindications noted If X-rays not taken, document reason (pregnant, recent films available, etc.)]

Diagnosis and Treatment Plan

Diagnosis / ICD-10 Codes
[Primary and secondary diagnoses: 1. M99.01 - Segmental and somatic dysfunction of cervical region 2. M99.03 - Segmental and somatic dysfunction of lumbar region 3. M54.2 - Cervicalgia 4. M54.5 - Low back pain 5. [Additional diagnoses as applicable] Include subluxation-related codes (M99.0X series) as primary when appropriate for chiropractic billing.]
Clinical Impression
[Summary of findings and clinical reasoning. Explain how examination findings support the diagnosis and why chiropractic care is appropriate. Address any complicating factors or comorbidities.]
Prognosis
[Expected outcome: Excellent, Good, Fair, or Guarded. Include factors affecting prognosis (chronicity, patient compliance, comorbidities, work demands).]

Treatment Plan

Treatment Frequency and Duration
[Example: 3x/week for 4 weeks, then 2x/week for 4 weeks, then 1x/week for 4 weeks. Re-evaluate at 12 visits.]
Planned Interventions
[Specific interventions planned: - Chiropractic Manipulative Treatment (CMT): Regions to be adjusted, technique(s) to be used - Soft Tissue Therapy: Myofascial release, trigger point therapy, instrument-assisted - Therapeutic Exercises: Stretching, strengthening, stabilization - Physical Therapy Modalities: E-stim, ultrasound, traction (if applicable) - Patient Education: Ergonomics, posture, activity modification]
Short-Term Goals (4 weeks)
[Measurable goals: 1. Reduce pain from ___/10 to ___/10 2. Increase cervical ROM to ___% of normal 3. Patient will be able to [specific functional activity] 4. Reduce muscle spasm/tenderness at [specific regions]]
Long-Term Goals (Discharge)
[Functional outcomes: 1. Return to full work duties without restrictions 2. Pain-free during activities of daily living 3. Independent with home exercise program 4. Achieve maximum therapeutic benefit / release to maintenance care]
Patient Education Provided
[Topics discussed: diagnosis explanation, treatment plan, expected response, home care instructions, activity modifications, ergonomic recommendations, red flags to report.]
Patient Consent
[Patient consented to treatment after discussion of risks, benefits, and alternatives. Informed consent obtained: Y/N]

Signatures

Doctor's Signature
[Signature]
Credentials
[DC]
License Number
[License #]
Date
[Date]

Tips for Writing Chiropractic Evaluations

A well-documented evaluation protects you legally, supports insurance reimbursement, and guides effective patient care. Here are tips for writing better evaluations.

Document Subluxations Thoroughly

Subluxation documentation is the foundation of chiropractic care. For each subluxation, document the specific level, direction of misalignment, associated soft tissue findings (spasm, tenderness, edema), and functional implications. This supports medical necessity for CMT.

Use Standardized Listing Notation

Use consistent subluxation listings that other chiropractors will understand. Common notation includes: P (posterior), A (anterior), R (right), L (left), I (inferior), S (superior). For example, C5 PRI means C5 is posterior, right, and inferior.

Connect Findings to Function

Don't just list impairments - explain their functional impact. "L4 subluxation with right paraspinal hypertonicity, limiting patient's ability to sit for more than 30 minutes at work" is more compelling than "L4 subluxation noted."

Be Specific with Measurements

Quantify everything possible. Use degrees for ROM, 0-10 for pain, specific grades for reflexes and muscle strength. These provide measurable baselines to demonstrate improvement at re-examination.

Document Medical Necessity

Your evaluation should clearly answer: Why does this patient need chiropractic care? What impairments require a chiropractor's expertise to address? How will treatment restore function? This is essential for insurance coverage.

Include Informed Consent

Document that you discussed risks, benefits, and alternatives to treatment, and that the patient consented to care. This protects you legally and meets board requirements.

Audit-Proof Your Documentation Insurance auditors look for: documented subluxation with specific levels, evidence-based examination findings, functional limitations, measurable goals, and appropriate treatment frequency. Missing elements can result in claim denials or recoupment.

How SOAP Note Buddy Helps with Chiropractic Evaluations

Chiropractic initial evaluations are comprehensive documents that can take 30-45 minutes to write manually. That's time away from patient care or your personal life.

Generate Complete Evaluations in Minutes

SOAP Note Buddy uses AI to dramatically speed up your evaluation documentation. Enter your examination findings and the AI generates a complete evaluation draft in your EHR.

What SOAP Note Buddy Does:

  • Auto-Detects Your EHR Fields: Works with ChiroTouch, EZBIS, Genesis, Jane, and any web-based system
  • Generates All Sections: History, examination, orthopedic/neurological testing, subluxation listings, and treatment plan
  • Understands Chiropractic Terminology: Proper subluxation notation, CMT descriptions, and chiropractic-specific language
  • Creates Compliant Documentation: Includes elements required for insurance and Medicare billing
  • HIPAA Compliant: Patient information is protected with automatic PHI removal

What used to take 30-45 minutes now takes 5 minutes of review and customization. That's 25-40 minutes saved per evaluation.

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Frequently Asked Questions

What should be included in a chiropractic evaluation?

A comprehensive chiropractic evaluation includes patient history (demographics, chief complaint, health history), physical examination (vitals, posture, ROM, palpation), orthopedic testing, neurological examination (reflexes, sensation, motor), spinal analysis with subluxation listings, and a detailed treatment plan with diagnosis, frequency, and goals. Each section should support the medical necessity for chiropractic care.

How do you document subluxation listings?

Subluxation listings document the location and direction of vertebral misalignment using standardized notation. For example, C5 PRI indicates C5 is posterior, right, and inferior. The documentation should include the specific segment, direction of misalignment, associated muscle involvement (spasm, tenderness), and functional implications. This is essential for Medicare and insurance reimbursement.

What is the Medicare requirement for chiropractic documentation?

Medicare requires documentation of subluxation by X-ray or physical examination, including the specific spinal level, evidence of dysfunction, a diagnosis related to the subluxation, and a treatment plan with frequency and duration. The evaluation must demonstrate that the treatment is active/corrective (not maintenance) and medically necessary.

How long should a chiropractic initial evaluation take?

A thorough chiropractic initial evaluation typically takes 45-60 minutes for the patient encounter, including history, examination, and X-rays if indicated. Documentation can take an additional 20-40 minutes manually. AI documentation tools like SOAP Note Buddy can reduce documentation time to under 5 minutes.

What orthopedic tests are commonly used in chiropractic evaluations?

Common orthopedic tests include cervical compression/distraction, Spurling's test for cervical radiculopathy, Kemp's test for lumbar facet involvement, straight leg raise (SLR) for disc herniation, Braggard's test, Patrick's FABER test for hip/SI pathology, Gaenslen's test, and Yeoman's test. Test selection depends on the patient's presenting complaint.

What ICD-10 codes do chiropractors use?

Chiropractors commonly use M99.0X codes for segmental and somatic dysfunction (M99.01 cervical, M99.02 thoracic, M99.03 lumbar, M99.04 sacral, M99.05 pelvic), along with pain codes (M54.2 cervicalgia, M54.5 low back pain, M54.6 thoracic pain) and condition-specific codes. The subluxation codes should be primary for chiropractic billing.

How often should chiropractic re-evaluations be performed?

Re-evaluations are typically performed every 12 visits or 30 days, whichever comes first. Some payers have specific requirements. Re-evaluations document progress, justify continued care, and update the treatment plan. They should compare current findings to baseline and demonstrate measurable improvement.

Can AI help with chiropractic evaluations?

Yes, AI documentation tools like SOAP Note Buddy can significantly reduce evaluation documentation time. Enter your exam findings and the AI generates a complete evaluation draft with proper subluxation documentation, orthopedic/neurological findings, and treatment plan. You review and customize the output, saving 25-40 minutes per evaluation.

Related Resources

Chiropractic Documentation AI SOAP notes for chiropractors All Chiro Templates SOAP, progress, discharge templates How to Write SOAP Notes Complete SOAP note guide All Templates Templates for all disciplines

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