Your patient, Polly W., is briefly introduced in the beginning of the following physical therapy initial evaluation note. She has been referred to your private practice by her family physician. Her insurance company has authorized 12 treatments. She reports she must have slept in a 'bad' position because she woke up with severe right sided neck pain and 'sinus' headache on Friday morning. She reports having been working long hours lately on a big project at work.
Stress is 'no more than usual'.
Sinus type headaches occur concurrently. About 2 years ago she saw a chiropractor, which helps considerably, and she has continued to receive adjustments on an irregular basis to alleviate recurrent episodes of neck pain. Most recent adjustment was 3-4 months ago. Patient believes another adjustment would help the current problem, but she decided to see the physician this time in hope of finding a way to prevent future episodes. Shows no evidence of fracture, disc narrowing or arthritic changes.