Patient's First Name
Patient's Last Name
Occi
M
Act
Trac
C-Spine
M
Act
D
Trac
Other
T-Spine
W
Act
Dth
Shc
O
L-Spine
D
DOB
SP
Act
Other
SAC
D
DOB
SP
ACT
Other
SI
L
R
DOB
D
SP
ACT
TMJ
ACT
M
Trac
Clavical
L
R
S-C
A-C
GH
L
R
PS
AL
Elbow
L
R
Wrist/Hand
L
R
Hip
L
R
D
Trac
M
Knees
L
R
D
M
Trac
Fib head
L
R
D
M
Ankle/Foot
L
R
M
D
T
Ribs
L
R
W
SHC
D
ACT
Trac
Note
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Please MARK where you are having symptoms on drawing
Patient Drawing Form
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