Ash Mnr Form PDF Details

The Ash Mnr form is a form of martial arts that has been practiced since the 1800s. The forms are named after their creator, William M. Ashman, who combined elements of many different styles to create this new style. There are four primary stances in the Ash Mnr Forms: Horse Stance, Cat Stance, Crane Stance and Mountain Stance. These four stances were created by combining aspects from other martial arts such as Karate and Kung Fu. This blog post will cover Horse stance and how it can be used for self-defense purposes.

In the list, there is some good information about the ash mnr form. You might like to browse it just before writing the form.

QuestionAnswer
Form NameAsh Mnr Form
Form Length2 pages
Fillable?Yes
Fillable fields286
Avg. time to fill out28 min 53 sec
Other namesash form physical therapy, ash mnr form physical therapy, cigna ash medical necessity review form physical therapy, cigna ash mnr form

Form Preview Example

American Specialty Health (ASH)

P.O. Box 509001, San Diego, CA 92150-9001

Fax: 877.248.2746

FOR ASH

ASH MNR FORM #

USE ONLY

 

MNR FORM – Acupuncture - Page 1

For questions, please call ASH at 800.972.4226

 

RECEIVED DATE

ASH CLINICAL QUALITY EVALUATION MANAGER

 

 

 

Patient Name

 

 

Sex M / F Birthdate

/

/

 

Patient ID #

 

 

Last

First

Initial

 

mm

 

dd

 

yyyy

 

 

Subscriber Name

 

 

Subscriber ID #

 

 

 

 

Employer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Primary

 

Health Plan

 

Secondary Group #

Is this?

PCP Name

 

 

 

Phone #

 

 

Work Related? Auto Related?

 

Clinic Name

 

 

 

 

 

 

 

 

 

 

 

PATIENT MAILING ADDRESS AND PHONE NUMBER

 

Treating Practitioner

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City/State/Zip

 

 

 

 

 

 

 

 

 

 

City/State/Zip

 

 

 

 

 

 

Phone (

 

)

 

Fax (

)

 

 

 

 

 

Phone (

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONDITION TREATED, DIAGNOSIS AND ICD-9 CODE

 

 

 

 

 

 

 

 

 

 

 

1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Acute Condition

 

Chronic Condition

Continuing Care

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Co-managed Care

Supportive Care

 

3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Eastern Diagnoses:

 

 

 

 

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TREATMENT/SERVICES SUBMITTING FOR REVIEW

Date: From ___ / ___ / _____ Through ___ / ___ / _____

Acupuncture

 

Electro-stimulation

Acupressure/Tui-Na

Home Care Advice

Total # Office Visits/Acupuncture

 

 

 

 

 

 

 

 

Diet

Cupping

Cold/Heat Pad

GuaSha

Herbs

Infrared/Heat Lamp

Established Patient Exam Date

 

 

 

 

 

 

 

Moxibustion

Rehab Exercise

Nutritional Supplements

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Estimated Date of Release

 

/ ___ __ / __ ____

Other

 

 

 

 

 

 

 

Treatment Goal:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Services provided prior to today and the treatment outcome:

Total # of Treatments _____ performed.

Patient’s response to care

 

Pain has

Decreased

No Change

Worsened

Decreased only for a short period of time

Functional Ability Change

Improving

 

No Change

Getting Worse. Explain:

 

 

Current main complaint(s)

Mechanism of injury/date of onset Traumatic Repetitive Exacerbation Recurrent / Chronic Unknown Post-Surgical

Pertinent health history

Other ongoing treatments (e.g., medications, therapies)

Height

 

____, Weight ___

 

lb, BP_____ / ______ mmHg,

Temperature

 

 

 

 

__, Pulse __________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Summary of your examination findings (or attach page 2): Date of exam

 

/

 

/

 

 

 

Findings:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Activities of Daily Living are normal

mildly affected

severely affected:

 

 

 

 

 

 

 

 

 

Observation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Palpation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Range of Motion

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Orthopedic Testing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Neurological Assessment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tongue Signs

 

 

 

, Pulse Signs R:

 

 

 

 

 

 

 

 

L:

 

Additional Clinical Findings

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PLEASE SUBMIT THIS FORM WITH INITIAL HEALTH STATUS (INITIAL CARE) OR PATIENT PROGRESS FORM (ONGOING CARE)

Signature of treating acupuncture practitioner

 

Date

 

 

 

 

AcuMNRForm041312.docx

American Specialty Health (ASH)

 

 

MNR FORM -Page 2 (OPTIONAL)

 

 

 

 

Acupuncture Clinical Findings

Patient Name

 

Occupation

Practitioner Name

 

 

 

 

 

 

Pain Descriptions:

Pain Condition #1: Location ________________ Intensity (1-10) _____ Frequency_______________ Duration________ hours/days

Pain is

Sharp

Dull

Stabbing

Burning

Spasmodic

 

Tingling

Throbbing

Stiffness

Distension or

 

 

Aggravating factors:

 

 

 

 

 

 

 

 

Alleviating factors:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pain Condition #2: Location

 

 

Intensity (1-10)

 

 

Frequency

 

 

Duration

 

hours/days

Pain is

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sharp

Dull

Stabbing

Burning

Spasmodic

 

Tingling

Throbbing

Stiffness

Distension or

 

 

Aggravating Factors:

 

 

 

 

 

 

 

 

Alleviating Factors:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Pain Conditions:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Clinical Findings Related to Pain Location:

Head:

Pain with Nausea/Vomiting Fever/Chills Dizziness Phono/Photophobia Neck Rigidity

Neurologic Deficit Sensation Strength Speech Vision Hearing Cognition Memory Eye Motion/Pupils React

Neck:

Tenderness at

Postural Abnormalities

Functional Limits

Back:

Mild

Moderate

Severe

Worsened.

Muscle Spasm

Mild

Moderate

Severe

 

 

Radiating Pain To

 

 

 

 

Tenderness at ________________

Mild

Moderate

Severe

Worsened.

 

Muscle Spasm

Mild

Moderate

Severe

Postural Abnormalities ________________

Scoliosis _____________________

Radiating Pain To

 

 

 

 

Functional Limits

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Extremities, Hip(s) and Shoulder(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

Tenderness at _______________

Mild

Moderate

Severe

Worsened.

Muscle Spasm

Mild

Moderate

Severe

Swelling _______________ Color change __________

Deformity

 

 

 

Radiating pain to

 

 

 

 

Functional Limits

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Neurologic Deficit Location

 

 

 

 

Weakness

Abnormal Sensation

Reflexes (Increased/Decreased)

ROM of Affected joint(s) Use measurement or indicate if ROM Within Normal Limits (WNL), mildly, moderately or severely limited:

Joints

Flexion / Extension

Lateral Flexion R / L

Rotation R / L

Rotation Int./Ext.

Abduction / Adduction

Other:

Orthopedic/Neurological Test Findings: E.g., Axial Compression ______ ; Patrick’s (Fabere) _______ ; Straight Leg Raising

Abdominal Pain:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Associate Symptoms: Fever

 

Nausea/Vomit

Gas/Distension

 

 

Heartburn/Reflux

Constipation

Diarrhea

or

 

 

 

 

Palpable Mass at

 

 

 

 

 

Tenderness at

 

 

 

Rebound Tenderness

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bowel Movement Sounds (Increase/Decrease)

 

 

 

 

 

 

 

 

Other Findings

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Menstrual Pain: Menstrual Cycle

 

 

 

 

days. Other Symptoms

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Additional Clinical Findings (including Lab / Radiographic Exams)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Outcome Assessments (List both Initial and Current date(s) with score(s) for applicable tests)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Initial

 

 

 

 

Current

 

 

 

 

 

 

 

 

 

 

Initial

 

Current

 

List Date Obtained

 

/

 

/

 

 

 

 

/

 

/

 

 

 

List Date Obtained

 

 

/

 

 

/

 

 

 

 

 

/

 

/

 

 

Roland-Morris score

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Neck Disability Index score

 

 

 

 

 

 

 

 

 

 

 

 

 

Oswestry score

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LEFS (Lower Extrem.) score

 

 

 

 

 

 

 

 

 

 

 

 

 

Pain scale (0-10) score

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DASH (Upper Extrem.) score

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of treating acupuncture practitioner

 

 

 

 

 

 

 

 

 

 

 

Examination Date (required)______________

 

AcuMNRForm041312.docx

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mnr form empty spaces to consider

The system will demand you to fill out the TotalOfficeVisitsAcupuncture, EstablishedPatientExamDate, Diet, Cupping, ColdHeatPad, GuaSha, Herbs, InfraredHeatLamp, Moxibustion, RehabExercise, NutritionalSupplements, EstimatedDateofRelease, Other, TreatmentGoal, and Painhas section.

step 2 to filling out mnr form

Describe the main details about the RangeofMotion, OrthopedicTesting, NeurologicalAssessment, TongueSigns, PulseSignsR, AdditionalClinicalFindings, Date, and AcuMNRFormdocx section.

Entering details in mnr form part 3

The PatientName, PainDescriptions, Occupation, PractitionerName, Aggravatingfactors, Alleviatingfactors, PainConditionLocation, Intensity, Frequency, Duration, hoursdays, AggravatingFactors, OtherPainConditions, AlleviatingFactors, and RadiatingPainTo area is the place where each party can put their rights and responsibilities.

mnr form PatientName, PainDescriptions, Occupation, PractitionerName, Aggravatingfactors, Alleviatingfactors, PainConditionLocation, Intensity, Frequency, Duration, hoursdays, AggravatingFactors, OtherPainConditions, AlleviatingFactors, and RadiatingPainTo blanks to fill

Finish by looking at the next sections and filling them out as needed: ExtremitiesHipsandShoulders, Joints, FlexionExtension, LateralFlexionRL, RotationRL, RotationIntExt, AbductionAdductionOther, PalpableMassat, Tendernessat, ReboundTenderness, BowelMovementSoundsIncreaseDecrease, OtherFindings, MenstrualPainMenstrualCycle, daysOtherSymptoms, and Initial.

mnr form ExtremitiesHipsandShoulders, Joints, FlexionExtension, LateralFlexionRL, RotationRL, RotationIntExt, AbductionAdductionOther, PalpableMassat, Tendernessat, ReboundTenderness, BowelMovementSoundsIncreaseDecrease, OtherFindings, MenstrualPainMenstrualCycle, daysOtherSymptoms, and Initial fields to fill

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