7/28/2019 Panacea Photonics Doctor Chart

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Panacea Quantum 1000 Light Therapy - Charting Record Date___/___/_____Patients Name _____________________________ Patient # __________Visit #______

Condition/Body Part Severity* ROM White Violet Minutes P.M.R.S.* (Y or N)Ear(s), Nose, Throat, Oral Cavity (circle one) ____ ____ ____ ____ ____ ____TMJ ___Right ___Left ___Both ____ ____ ____ ____ ____ ____Headache(s) category* _______________ ____ ____ ____ ____ ____ ____ Describe anyShoulder ___ Right ___Left ___Both ____ ____ ____ ____ ____ ____ unique orScapula ___Right ___Left ___Both ____ ____ ____ ____ ____ ____ patientClavicle (S/C Jt.) ___Right ___Left ___Both ____ ____ ____ ____ ____ ____ specificElbow ___Right ___Left ___Both ____ ____ ____ ____ ____ ____ observations

Wrist ___ Right ___ Left ___Both ____ ____ ____ ____ ____ ____ in the spaceFinger(s) ___ Right ___ Left___ Both ____ ____ ____ ____ ____ ____ below..Thumb ___ Right ___ Left ___Both ____ ____ ____ ____ ____ ____Carpal Tunnel S. ___Right ___Left ___Both ____ ____ ____ ____ ____ ____Cervical Spine ___Right ___ Left ___Both ____ ____ ____ ____ ____ ____Thoracic Spine ___Right ___ Left ___ Both ____ ____ ____ ____ ____ ____Ribs/Intercostal ___Right ___Left ___Both ____ ____ ____ ____ ____ ____Lumbar Spine ___ Right ___ Left ___Both ____ ____ ____ ____ ____ ____Lumbo-sacral Spine ____ ____ ____ ____ ____ ____Sacro-Iliac Joint(s) ___Right ___Left ___Both ____ ____ ____ ____ ____ ____Coccyx ____ ____ ____ ____ ____ ____Hip/Acetabulum ___Right ___Left ___Both ____ ____ ____ ____ ____ ____Knee ___Right ___ Left ___Both ____ ____ ____ ____ ____ ____Ankle ___Right ___ Left ___ Both ____ ____ ____ ____ ____ ____Heel(s)/Pl.Fascia ___Right ___Left ___Both ____ ____ ____ ____ ____ ____Arch Pain ___Right ___Left ___Both ____ ____ ____ ____ ____ ____Metatarsalgia ___ Right ___ Left ___Both ____ ____ ____ ____ ____ ____Toes ___ Right ___ Left ___Both ____ ____ ____ ____ ____ ____Bunion(s) ___ Right ___ Left ___ Both ____ ____ ____ ____ ____ ____

Muscles: Spasm, Strain, Contusion, Twitch, (circle one) Other _________________(i.e. spinal mms, hamstrings, TFL, calf, shin, buttocks, etc.)1.___________ 2. ____________ ____ ____ ____ ____ ____ ____

Generalized and Systemic Conditions

(i.e. fibromyalgia, restless leg syndrome, tinnitus, neuropathy, rheumatoid arthritis, lupus, etc.)1.___________2. _____________ ____ ____ ____ ____ ____ ____

Skin Condition/Nails(i.e. acne, psoriasis, scarring, varicose ulcer, ringworm, finger/toenail fungus, etc.)1._________________ 2. _______________ ____ ____ ____ ____ ____ ____

Patient Response (describe % of improvement)___% Worse ___No Change ___ % Slight Improvement ___% Moderate Improvement___ % Significant Improvement ___ Full Resolution

Comments/Remarks (include any observed adverse effects) _______________________________________________________________________________________________________________________________

* Severity: Grade on a scale of 1-10, with 1 representing very mild to 10 very severe.* Identify category of headache(s) - i.e. cervicogenic; migraine; cluster; tension, etc.* Indicate yes or no, (Y or N) whether the topical Panacea Miracle Relief Spray was used in the treatment.