On June 04, 2020 a
Exhibit,Appendix
was filed
involving a dispute between
State Farm Fire And Casualty Company,
State Farm Mutual Automobile Insurance Company,
and
Perloff Physical Therapy, P.C.,
for Other Matters - Contract - Other
in the District Court of Kings County.
Preview
FILED: KINGS COUNTY CLERK 07/25/2022 04:37 PM INDEX NO. 509187/2020
NYSCEF DOC. NO. 36 RECEIVED NYSCEF: 07/25/2022
"H"
EXHIBIT
FILED: KINGS COUNTY CLERK 07/25/2022 04:37 PM INDEX NO. 509187/2020
NYSCEF DOC. NO. 36 RECEIVED NYSCEF: 07/25/2022
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF KINGS
-------..______-______----..___.._.._______..----..____Ç
TAREEK J. FORDE,
.
Index No. 509187/20
Plaintiff, CERTIFICATION AND
- AFFIRMATION
OF MEDICAL RECORDS
-against-
MOHAMMED R. AMIN and SAJJAD HOSSAIN,
Defendants.
-------__..----------------..______-___,.--------X
Omar Ahmed, M.D., affirms to the truth of the following pursuant to CPLR§2106:
1. I am not a party to the above action, I am a chiropractor duly licensed in the State of
New York and I affirm the following statements to be true under the penalties of
perjury.
2. This certification is made pursuant to CPLR§3122-a for the purpose of avoiding the
need for a member of my office staff to come to court to testify as to the authenticity
and completeness of the attached records, which are maintained by my office staff
with regard to the plaintiffs, patients of my office, who would so testify if called that
the attached records are maintained in the ordinary course of my practice.
3. This certification is furnished by me because I am qualified to do so, and since I have
the authority to make this certification/affirmation as the above entity is my office
of business and I am the ultimate custodian of these records.
4. To the best of my knowledge, after reasonable inquiry, the copies of the records
attached hereto are accurate versions of the documents that are in possession,
custody,or control of my office.
5. To the best of my knowledge, after reasonable inquiry, the copies of the records
attached hereto represent my office records.
6. The copies of the records attached hereto were made by the personnel or staff of the
business, or persons acting under my control, in the regular course of business, at the
FILED: KINGS COUNTY CLERK 07/25/2022 04:37 PM INDEX NO. 509187/2020
NYSCEF DOC. NO. 36 RECEIVED NYSCEF: 07/25/2022
time of the act, transaction, occurrence or event recorded therein, or within a
reasonable time thereafter, and that itwas the regular course of business to make
such records.
7. I am TAREEK J. FORDE 'streating doctor, licensed to practice medicine in the state.
of New York and I affirm under penalties of perjury that the records attached are
authentic and complete. The records attached are maintained in the ordinary course
of my practice.
,
Dated: July 7, 2022
Brooldyn, New York
On r Ahmed, IV D.
FILED: KINGS COUNTY CLERK 07/25/2022 04:37 PM INDEX NO. 509187/2020
NYSCEF DOC. NO. 36 RECEIVED NYSCEF: 07/25/2022
Phwal Therapy ProgTess Noies
PATIENT NAME: AG E: 4 D.O. A:
DIAGNOSIS: M/S. LIG SPRAIN / STRAIN
dÇ
PRECAUTIONS: PlfYSICIAN: Omar Ahmed MD
Date: F - Mild Moderate Sever
Subjectivecom plaints: PAIN LEVEL: 0 I 2 3 4 5 6 7 8 9 10
PT reports:J4·ntCchange in symptoms [ ] Slight
improvement [ ] Continued
improvement [ ] exacerbation
of symptoms
Patient c/o sjdl0k Pain [ ] MiddleBack Pain -HTi*•v Back Pain O IVR Shoulder Pain Elbow
[ ] L/R Pain
0 UR Wrist Pain [ ] UR Hip Pain [ ( K.nec Pain Ankle
[ ] L/R Pain [ ] URFoot Pain
OhicctiveFindiergs:
[ ) Muscle. Spasm[ ] Tenderness [ 1 MMS. Weakness
[ ] Tightness [ ] Deformity [ ] Trigger point
[ ] Other:
[ I No change in physicai since last v isit
findings [ [ Newphysical
exam findingsare ___
Treatment "
-.f[-
Plan 2/ Cold Pack-.... ...._[4-TMefapeutic/
M)5Ïcinifylahage [ ] Myo fascist
Release Exercisc
[ ] Therapeutic
U
eiri.ci Jiiit]pn/lins[ I Paraifin
Wax Bath [ ]Ul(rasound [ ] other:
Assessment:_4| Pliem toleratedtreaiment
well [ ]Change pan ofcare
Platy |TContinue PT management given [ I Discharge
the Patient
from therapy
Therapist's Signuture: ---
PatienU Signature:X
( I CertifythatI bavereceivedthefollowmgIreatmentby P.T/P.TA).
Date: Mild Moderate Sever
Subjectivecam plaints: PAIN LEVEL: 0 1 2 3 4 5 6 7 8 9 10
PT reports:-4 o changein symptoms [ ] Slight
improvement [ } Continued
improvement [] exacerbation
ofsymptoms
ipck
Patient c/o Pain [ ] Middle
Back Pain JJ,ow Back Pain [ ] UKShouldetPain [ ] URElbow Pain
[ ] UR WristPain [ ] UR Hip Pain I 1 Knce Poin [ ] URAnkle Pain { ] URFool Pain
O) cctive
Findings: [ ] Muscle.Spasm[ ] Tendemess [ ] Tightness
[ ] MMS. Weakness [ ] Defom1ity[ ] Trigger poini| I Other:
-
[ ]No change in physical
findingssince lasf visit T] New physi'cal exarh findings
are
Treatment Plan ,ji I / ColdI ack -{ Tlic'rapeutic/
dech?2dc I lals [ ] Myofascial
Reicase [ ] Therapeutic
Exercise
J Íectrical
StinÈlotion/rens [ ] Paraflin
Wax Bath O Ultrasound [ ] other:
Assessmentn[4fatient tolerated
treatmentwell {] Change pan of care
Plpn: - Continuc Pf mailagetagnt
[f
15ationt'
$iginature: X Èh (
/QÓ.b P|r/P.TA).
Therapisi'sSiganturct · (1 certify thát t havercccivedthe following treatmeåtby
}
- Moderate.. Sever . ...
Mpd
Dutc : . h ..
0 I 2. 3 4 5 6 7 8 9 10
PAIN LEVEL:
Sub jectivecomplaints: ofsymptonYs
improvement [ ] Continued
improvement - [ ] exaccrbution .."
'PT reports: ^[] no chaDge in gyfnptoms .[ ] Slight Elbow Pain
Pain [2low Back.Pain [ }UR ShouliterPain [ ]UR
Patientc/o : [ Neck Pain [ ] MiddleBack
UR Ankle Pain [ JUR Foot Pain
Pain [ ] L/RKnee Pain []
. [ ] UR Wrist Pain [ ] UR Hip
[]Trigger poittt []Other.
MMS. Weakness [}Deformity
Ob jectiveFin dinns:[. J Moscic.'Spasm(.] Tenderness [ ] Tightness[]
physicalexam findingsare
]· No'change findings
in physical sincelast,visit O New
[ TherapeuticExercise
Mechdnic¾I Massage MyofascialRelease []
Cold Pack [Therupeutic/ O
Treatment Plan HoÌ/
Ultrasound []other
al timulation/Tens ] Wax
Parallin Bath O
ˆlect i
Change pan of care
Assessnient: Patienttoleratedtreatmentwelf O
[ ]
Discharge the Patient
from therapy
Pian.: Continuc PTinanagertientgiven O
[
Patient' Signature: X / O/f
Therapist's Signature: receivedthe following grearkentty P.T/P.TA).
( I Certify that Ihave
NOSTRAND AVE. BROORTWN. NY nSSG
MODICRN BROOHLTN MEDICAL PC 1201
fr.T. A: Physicalrherapin Assian
P T- PImimilberap8t
FILED: KINGS COUNTY CLERK 07/25/2022 04:37 PM INDEX NO. 509187/2020
NYSCEF DOC. NO. 36 RECEIVED NYSCEF: 07/25/2022
rlwsicainerapvProgressNotes
AGE: D.O. A:
NAME: (i (iy
PATIENT f STRAM
DIA.GNOSIS: C 71 C9 M/S. LIG SPRAIN /
FHVSICIAN: Omar Ahmed MD
PRECAUTIONS: Modera te S-:ver
Mild
Date: , .- 10
LEVEI.,: 0 I 2 3 4 5 6 7 8 9
PAIN
Subicetiveenm plainis: improvement exacerbationof symptoms
Slightimprovement [ ] Continued [ ]
PT reports: [ ] no ange in symptoms UR Elbow Pain
{J..1sdvBack Pain {] UR Shoulder Pain [f
Back Pain
Patientc/e: [Q eckPain {.] Middic
Ankle Pain ()L/R Foot Pain
Pairl [ L.L(fÇÉnecPain [ ] L/R
IJR -WristPain [ .] URHip
{ ) TdggcWpoint [ J Other:
[ I Tendemess [ ] Tightness[ ] MMS. Weakness [ ] Dermity
Objective Findings:[ ] Muscle. spasm
physicalexam findingsarc
change findings
in physical sincc last visit { ] New
[ ] No
fxercise
Pack- -- -- Mec)(a
[of-Therapeutic/ icÃ1Massage ]Myofascial Release ] ThWpeutic
Treatment Plari L. Cold ...
.., Ultrasound other:
[.]
j- aÙStimulationfrens ParaffinWar Bath [ ]
ectr []
treatmentwell Change pan of care
Assessment: toicrated
a icut [ ]
nicutgivens from
the Patient
I Discharge therapy
Continue PT mana [
han: 1]
, P-atienttSignature:
.Therapist'sSignat tre: ( I Certify th lowliig treatmentby P-T/F.TA).
,'
Mild Moderate Sever
Date i "^f.
0 1 2 3 .4 5 6 7 8 9 10
PAIN LEVEL:
Subjectivecom plaints: improvement exiccrbationofsymptorns
improvement [ ] Continued {]
PT reports: [ ]no change in symptoms ( ] Slight R Elbow Pain
Ç}1w Back Pain . O UR Shoulder Pain [] 1
. [d.NiÍckPain U.Middic Back Pain
Patient-c/o
: " ---
{/R'Ankle Pain [ ] UR FootPairr
Pain Ki fPain .
Wrist Pain [ ]UR Hip .
[ ] US ]0ther
O MMS. Weakness O Defom°ty [ ] Trigge
poitat
Ob jectiveFindings: Muscle.Spasm
[-J (,) Tendemess O Tightness
[]New physicalexain findingsani '--
cliangein physicalfindingssinceinst visit
[ ) No Exercisc
Therapeutic/ nicalMassage O Myofascial Release [ ] Therapeutic
Trea tment Plan Pack
t / Cold [.] -'
other-
ParaffinWax Bath . [] Ultrasound O
] [ ]
cc°(iegi/Stiniulation/Tens.
treatmentwell Change pan of care
Assessment: tolerated
Patient [ ]
[
· Discharge from
the Patient therapy
an: - Continue PT mabaq cutgivtin O
. Patienb Sigeniture: X (1 f
TherapisPs Signaturet mt Ihaverecered the E1Iowingrecateciitby P:7/rl.A).
( 1Certiry
-w01d · woderate- Sever
pate : . 10
LEVEL: 0 I 2 3 4 5 6 7 8 9
PAIN
Subicctivecomplaints: - of
c×acerbation symptortis
improvement Continued improvement [ ]
in gyruptoms ·[ ] Slight O
TT reports: '[ ] no chañgc ShoulderPain O UREibow PaiI ..
Middle Back Pain [_1Lo¶
Back.Pain [ ] UR
Patientc/o: L}Neck Pain D
Ankle Pain O UR FootPain
E R nec Pain [ ) UR
* - . O UR WristPain [ ] UR Hip Pain
MMS. Weakacss [ ] Òeformity [ ) Trigger point [ I Other:
Objective Findings:[.1Muscic.spasm [.]Teaderness O Tightness [I
exam findingsare
]· No'change findings
in physical sincelastvisit O New physical
[ Exercise
Therapeutic
Myofascial Release []
Pack
DJfferapeutic/ cha icalMassage O
Treatment Plan / Cohl other-
d Ultrasound
Wax
Para flin Bath [ ] [ ]
Ekctri I Stinfulationffens [ ]
6
treatmentwell [ ]Change pan of care
Assessment: Patienttolerated
-
Dischargethe Patientfromtherapy
Plan: Continue PT managpfnent given O
w[3
Patient' Signature: X fro
Signattere: eceived Elfowing armentby P.T/P.T.A).
Therapist's ( I Ccedfythat I have
A G. 33ROOKCNN. NY 21sM
MODERN IIROOKLYN MEDICAL, PC 1901 NOSTRAND
T. At rhysicalThera
PW rttyrical Therepintr E s etam
FILED: KINGS COUNTY CLERK 07/25/2022 04:37 PM INDEX NO. 509187/2020
NYSCEF DOC. NO. 36 RECEIVED NYSCEF: 07/25/2022
Èhysicar0terapy Progress Notes
NAME: Y 7 /L AGE: D.O. A: O
PATIENT &C
M/S. LIG SPRAIN / STRAIN
DIAGNOSIS:_ JVU2
PRECAUTIONS: PHVSICIAN: Omar Ahmed MD
Mild Moderate S-:ver
Date:
LEVEL: 0 I 2- 3 4 5 6 7 S 9 10
SubjecNve complain t: PAIN
PT reports: .no changein symptoms impmvement
{ ] Slight
improvement
[ ] Continued [ ] exaccrbatioI
ofsymptoms
[
Back Pain -CEw Back Pain · UR ShoulderPain [] UR Elbow Pain
Patientc/o : . ] Nect:
Pain []Middle []
AnklePain UR FootPain
[ ] UR WristPain [ ·}UR Hip Paid Knec
{ ] L/R Pain [ ] L/R [}
MMS. Weakness Triggerpoim []Oiher:
ObicctiveFindings: [ ] Muscle. Spasm[]Tenderness [ J Tightness
[} [)Deformity []
since hastvisit New physicatexam lindingsarc
[ No cha go in physical
findings []
Treatment PInn ‰ot/ Cold Pack · - -
4 Therapeutic/
Mechan Massage Reicase
[ J Myofascial [ ] Therapeutic
Exercise
Bath Ultrasound []othed
[ ]ÓectricalStimulationfTens [ ] ParamnWax []
A_ssessmene atient treatment
tolerated well [ ]Change pan of-care
[
Plan.: PT mimagenient
.'ontinue given the Patient
f ] Discharge fromtherapy __
[
Patient'
Therapist's Signapzre: . Signature: X. .
- a nave receivedoic roIrowir,straarme.ni
(Iceniry: byP.T/P.T4).
; |
- .- -- Mild Moderate Sever
Date :
PAIN LEVEL: O 1 2.3 4 5 6 7 8 9 10.
Subicctive comptaints:
improvement
Slight Continued improverrient []exacerbationofsymptoms
PT reports: [ } no changein symptoms [] []
Pain Shonider Pain [ ] URElbow Pain
Patientc/o: - (JNeik Pain []Mi(idicBack Pain t{y-1%GTBack [ ] UR
WristPain Pain {]IJA'Koec Pain []·fJR'AnklePain [ ] URFoot Pairl
[ ] UR [ )URHip
MMS. Weakness []migger poirtt []Other: s
Obicctive Findings:I ] Muscle.Spasm [1Tenderness [ ]Tightness [] []Defomúty
No cliangein physical
findingssincelast visit O New physicalexam findingsare
[]
Treatmene Plan /Cold Pack 1-)4^herapeutic/
Mecl I Massage Rolcase
[ ] Myofascini [ ] Therupcutic
Excrcise
[
Wax
Paraffin Bath . Ultrasound []other:
[GJeeti )tiniulatinn/rens.
[) []
Assessment: Patienttolerated well
treatment Change
.[ ] pan of ca.rc
. P_[an. ContinuePT man gcmentgiün the i'atient
[ ] Discharge fromtherapy
£[ ]
Patient'siganture:X
Therapisi's Signature: rottowingneatmeiitbyP.T/P.T.A).^
that thaverece vedtl e
(Icertir
. -r Mild Moderate - Sever ...
PAINLEVEI2 0 -1 2. 3 4 5 6 7 8 9 10
SubicetWe complaints:
' improvement - [}exacer ätion of symptons
PT reports: ]no,change ingyrhptorns [ JSlightimproverpent [) Continued
[
M·iddle BackPain ow Back.Pain []UR Shoulder Pain .. []JJR Elbo• Pain .
Patientc/o: [QNeck Pain [} Q
UR WristPain [ ] UR Hip Pain { J URKnee Pain [] UR Ankle Enin [ ] UllFool;Paiti
[]
'
[.]Tendcmess Tightiess MMS. Weakness []_eformity []Trigger poiru []Other:
Objective Findings: [_] Muscle. Spasm [] []
}·No chan findings
in physical since Inst visit [ ]New physicalexam findingsare
[
{_].-IfÎerapeutic/
Mcci m lal Massage MyofascialRelease . O TherapputicExercjse
Treatment Plan ot)Cold Pack []
Bath'
=
timulation/Tens ParaffinWax O O7raspund []other
L] IcctÓ [)
bsgessment: PatienttoFcrated treatment
well { }Change pan of care .
fContinue PT i a agement givcu [ ] Dischargethe Patient
from therapy
Plan:_
Patient'Signature: K f (
Therapist's Signature: .
that1Imve scccivedthe followinggrcirment
(IOcpiry by PT M).
FILED: KINGS COUNTY CLERK 07/25/2022 04:37 PM INDEX NO. 509187/2020
NYSCEF DOC. NO. 36 RECEIVED NYSCEF: 07/25/2022
imicalTJierapvProgressNotes
PATIENT NA ME: vfr (WS Cú¾ AGE: AS D.O.A: $4
D IAGNOSIS: . Q() M/S. LIG SPRAIN
MD'
/ STRAI
- PHYSICIAN: Oma'r Ahmed
PRECAUTIONS:
Mild Moderate S--ver
Date:
0 1 2· 3 4 5 6 7 8. 9 10
Subjective PAIN LEVEL:
com pin m is:
improvenynt Continued improvement of syrnptoms
[ ] exacerbation
PT reports: [ ] no ,hange in symptoms [ ] Slight []
Q1.ny Back Pain · UR Shoulder Pain [ J UR Elbow Pain
Patientc/o : [Q!feck Pain Middle
[ ] Back Pain [}
Knee
[ ] (JR Pain . [ ] URAnkic Pain [ ] I.JR Foot
Pain
O UR WristPaih [ -] L/R
Hip Paid
. [ ] Ttigger-point []Other:
Findinps:
Obicct.ive [ ] Muscle.Spasm [ ] Tendemess [}Tighmess [ ] MMS. Weakness [ ] Derormity
last vjsit physicalexam arc
finding;s
[ [ No cha iri physicid·findlings
since [ j
Treatment Pt:in Cold PackA - E-l· lerapeutic/
Mc cal Massage Releas.c
- [ ] Myofasci:il Exercise
[ ] Therapeutic
lßEimulation/Tens ParaffinWex Bath [ ] ·Ultnsound othen.
.. [.]
h} cu ¤
Assessment:ÊPatient treatment
tolerated well [ JChange pan of care
from
the Patient
P_lan Continue-PT agenient given [ ] Discharge therapy
aticIttSignature: X O
Therapist'sSigns eure:
P-TP.T.c).
( I Cenify thit t havereceivedthe followingtecament·by
. Mild : Moderate Sever
Date : . .
PAIN LEVEL: O 1 'i. 3 ..it
.5 6 7 8 9 10.
Subicctive complainis
improvement Continued imprbvement [] cDcerbationofsymptoms
PT reports: [ ] no changein symptoms [] Slight []
J.MiddleBack Pain [].hn ack Pain . IJR Shoulder Pàin []UR EÏbow Pain
Patient-c/o:- D-]3iecEfain [ [}
UT é Pain []·&R'Ankle fain [] R Foot Pain
J UR WristPain [] UR Hip Pain [
MMS. Weakness Deformity []Trigg
r point []Lther:,: .
Obicctive Findings: [ ] Tightness
[ Ï} Mkscic. Spasm . .[] Tende ness [] []
[]New physicalexam are.
findings ..
]No clian9 in physical since
findings last visit
[
ReIc so -
herapeutic.Exercise
Treatmeni Plan ]- ol Cold Pack Werapeutic/ Mechani Massage [ ] Myofasciàl []
cr SÈniulation/rens. Wax
[ ] Paraffin Bath . [ ]Ultrasound . [ ] other:
[
Assessment Patient treatment
tolerated Well Change
.[ ] pan of care
'.lan: ÓontinuePT managem9nt gi tlic l'atient
[ ] Discharge from therapy
Patient'
Thera pis s Signaturia / Siginiture:X
. ( I Cersy d arI haven-ceivedthefollowingfreatest by P:rtP.T.A),
.
Mi d Nfoderate · - Sever
Date : .
PAIN LEV.EL: 0 I 2. 3 4 5 6 7 8 9 10
Su b jective
com plaints:
improvement.. on of symptoms
[ ] exacerbiit
'PT reports: { 6 chaitgein _yinptoms O Slight improvement [ ] Continued
,[' ShoulderPain UR Elbow Pain ..
Patientc/o : ] Neck Pain [ ] Midd
te BackPain [ ] LowBack.Pain [] L/R []
Knec Pain UR Ankle Pain . [ ] UR FootPairi
[ ] UR WrfstPain [ ] UR Hip Pain [ ] L/R []
-
[ ]Tenacmess O Tishtness [ ] MMS.weakness []beformity [ ]fTrigger
point [] Other:
Ob jective
Findings: [. ] Muscie.S pasm
"
exarn are
findings
[ Óo change findings
in physical v isit
since:last [ ] Newphysical
V]'Ýherapeutic/Mcch at Massage Release
[ ] Myofascial []Tlierapeutic
Document Filed Date
July 25, 2022
Case Filing Date
June 04, 2020
Category
Other Matters - Contract - Other
For full print and download access, please subscribe at https://www.trellis.law/.
Preview
FILED: KINGS COUNTY CLERK 07/25/2022 04:37 PM INDEX NO. 509187/2020 NYSCEF DOC. NO. 36 RECEIVED NYSCEF: 07/25/2022 "H" EXHIBIT FILED: KINGS COUNTY CLERK 07/25/2022 04:37 PM INDEX NO. 509187/2020 NYSCEF DOC. NO. 36 RECEIVED NYSCEF: 07/25/2022 SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF KINGS -------..______-______----..___.._.._______..----..____Ç TAREEK J. FORDE, . Index No. 509187/20 Plaintiff, CERTIFICATION AND - AFFIRMATION OF MEDICAL RECORDS -against- MOHAMMED R. AMIN and SAJJAD HOSSAIN, Defendants. -------__..----------------..______-___,.--------X Omar Ahmed, M.D., affirms to the truth of the following pursuant to CPLR§2106: 1. I am not a party to the above action, I am a chiropractor duly licensed in the State of New York and I affirm the following statements to be true under the penalties of perjury. 2. This certification is made pursuant to CPLR§3122-a for the purpose of avoiding the need for a member of my office staff to come to court to testify as to the authenticity and completeness of the attached records, which are maintained by my office staff with regard to the plaintiffs, patients of my office, who would so testify if called that the attached records are maintained in the ordinary course of my practice. 3. This certification is furnished by me because I am qualified to do so, and since I have the authority to make this certification/affirmation as the above entity is my office of business and I am the ultimate custodian of these records. 4. To the best of my knowledge, after reasonable inquiry, the copies of the records attached hereto are accurate versions of the documents that are in possession, custody,or control of my office. 5. To the best of my knowledge, after reasonable inquiry, the copies of the records attached hereto represent my office records. 6. The copies of the records attached hereto were made by the personnel or staff of the business, or persons acting under my control, in the regular course of business, at the FILED: KINGS COUNTY CLERK 07/25/2022 04:37 PM INDEX NO. 509187/2020 NYSCEF DOC. NO. 36 RECEIVED NYSCEF: 07/25/2022 time of the act, transaction, occurrence or event recorded therein, or within a reasonable time thereafter, and that itwas the regular course of business to make such records. 7. I am TAREEK J. FORDE 'streating doctor, licensed to practice medicine in the state. of New York and I affirm under penalties of perjury that the records attached are authentic and complete. The records attached are maintained in the ordinary course of my practice. , Dated: July 7, 2022 Brooldyn, New York On r Ahmed, IV D. FILED: KINGS COUNTY CLERK 07/25/2022 04:37 PM INDEX NO. 509187/2020 NYSCEF DOC. NO. 36 RECEIVED NYSCEF: 07/25/2022 Phwal Therapy ProgTess Noies PATIENT NAME: AG E: 4 D.O. A: DIAGNOSIS: M/S. LIG SPRAIN / STRAIN dÇ PRECAUTIONS: PlfYSICIAN: Omar Ahmed MD Date: F - Mild Moderate Sever Subjectivecom plaints: PAIN LEVEL: 0 I 2 3 4 5 6 7 8 9 10 PT reports:J4·ntCchange in symptoms [ ] Slight improvement [ ] Continued improvement [ ] exacerbation of symptoms Patient c/o sjdl0k Pain [ ] MiddleBack Pain -HTi*•v Back Pain O IVR Shoulder Pain Elbow [ ] L/R Pain 0 UR Wrist Pain [ ] UR Hip Pain [ ( K.nec Pain Ankle [ ] L/R Pain [ ] URFoot Pain OhicctiveFindiergs: [ ) Muscle. Spasm[ ] Tenderness [ 1 MMS. Weakness [ ] Tightness [ ] Deformity [ ] Trigger point [ ] Other: [ I No change in physicai since last v isit findings [ [ Newphysical exam findingsare ___ Treatment " -.f[- Plan 2/ Cold Pack-.... ...._[4-TMefapeutic/ M)5Ïcinifylahage [ ] Myo fascist Release Exercisc [ ] Therapeutic U eiri.ci Jiiit]pn/lins[ I Paraifin Wax Bath [ ]Ul(rasound [ ] other: Assessment:_4| Pliem toleratedtreaiment well [ ]Change pan ofcare Platy |TContinue PT management given [ I Discharge the Patient from therapy Therapist's Signuture: --- PatienU Signature:X ( I CertifythatI bavereceivedthefollowmgIreatmentby P.T/P.TA). Date: Mild Moderate Sever Subjectivecam plaints: PAIN LEVEL: 0 1 2 3 4 5 6 7 8 9 10 PT reports:-4 o changein symptoms [ ] Slight improvement [ } Continued improvement [] exacerbation ofsymptoms ipck Patient c/o Pain [ ] Middle Back Pain JJ,ow Back Pain [ ] UKShouldetPain [ ] URElbow Pain [ ] UR WristPain [ ] UR Hip Pain I 1 Knce Poin [ ] URAnkle Pain { ] URFool Pain O) cctive Findings: [ ] Muscle.Spasm[ ] Tendemess [ ] Tightness [ ] MMS. Weakness [ ] Defom1ity[ ] Trigger poini| I Other: - [ ]No change in physical findingssince lasf visit T] New physi'cal exarh findings are Treatment Plan ,ji I / ColdI ack -{ Tlic'rapeutic/ dech?2dc I lals [ ] Myofascial Reicase [ ] Therapeutic Exercise J Íectrical StinÈlotion/rens [ ] Paraflin Wax Bath O Ultrasound [ ] other: Assessmentn[4fatient tolerated treatmentwell {] Change pan of care Plpn: - Continuc Pf mailagetagnt [f 15ationt' $iginature: X Èh ( /QÓ.b P|r/P.TA). Therapisi'sSiganturct · (1 certify thát t havercccivedthe following treatmeåtby } - Moderate.. Sever . ... Mpd Dutc : . h .. 0 I 2. 3 4 5 6 7 8 9 10 PAIN LEVEL: Sub jectivecomplaints: ofsymptonYs improvement [ ] Continued improvement - [ ] exaccrbution .." 'PT reports: ^[] no chaDge in gyfnptoms .[ ] Slight Elbow Pain Pain [2low Back.Pain [ }UR ShouliterPain [ ]UR Patientc/o : [ Neck Pain [ ] MiddleBack UR Ankle Pain [ JUR Foot Pain Pain [ ] L/RKnee Pain [] . [ ] UR Wrist Pain [ ] UR Hip []Trigger poittt []Other. MMS. Weakness [}Deformity Ob jectiveFin dinns:[. J Moscic.'Spasm(.] Tenderness [ ] Tightness[] physicalexam findingsare ]· No'change findings in physical sincelast,visit O New [ TherapeuticExercise Mechdnic¾I Massage MyofascialRelease [] Cold Pack [Therupeutic/ O Treatment Plan HoÌ/ Ultrasound []other al timulation/Tens ] Wax Parallin Bath O ˆlect i Change pan of care Assessnient: Patienttoleratedtreatmentwelf O [ ] Discharge the Patient from therapy Pian.: Continuc PTinanagertientgiven O [ Patient' Signature: X / O/f Therapist's Signature: receivedthe following grearkentty P.T/P.TA). ( I Certify that Ihave NOSTRAND AVE. BROORTWN. NY nSSG MODICRN BROOHLTN MEDICAL PC 1201 fr.T. A: Physicalrherapin Assian P T- PImimilberap8t FILED: KINGS COUNTY CLERK 07/25/2022 04:37 PM INDEX NO. 509187/2020 NYSCEF DOC. NO. 36 RECEIVED NYSCEF: 07/25/2022 rlwsicainerapvProgressNotes AGE: D.O. A: NAME: (i (iy PATIENT f STRAM DIA.GNOSIS: C 71 C9 M/S. LIG SPRAIN / FHVSICIAN: Omar Ahmed MD PRECAUTIONS: Modera te S-:ver Mild Date: , .- 10 LEVEI.,: 0 I 2 3 4 5 6 7 8 9 PAIN Subicetiveenm plainis: improvement exacerbationof symptoms Slightimprovement [ ] Continued [ ] PT reports: [ ] no ange in symptoms UR Elbow Pain {J..1sdvBack Pain {] UR Shoulder Pain [f Back Pain Patientc/e: [Q eckPain {.] Middic Ankle Pain ()L/R Foot Pain Pairl [ L.L(fÇÉnecPain [ ] L/R IJR -WristPain [ .] URHip { ) TdggcWpoint [ J Other: [ I Tendemess [ ] Tightness[ ] MMS. Weakness [ ] Dermity Objective Findings:[ ] Muscle. spasm physicalexam findingsarc change findings in physical sincc last visit { ] New [ ] No fxercise Pack- -- -- Mec)(a [of-Therapeutic/ icÃ1Massage ]Myofascial Release ] ThWpeutic Treatment Plari L. Cold ... .., Ultrasound other: [.] j- aÙStimulationfrens ParaffinWar Bath [ ] ectr [] treatmentwell Change pan of care Assessment: toicrated a icut [ ] nicutgivens from the Patient I Discharge therapy Continue PT mana [ han: 1] , P-atienttSignature: .Therapist'sSignat tre: ( I Certify th lowliig treatmentby P-T/F.TA). ,' Mild Moderate Sever Date i "^f. 0 1 2 3 .4 5 6 7 8 9 10 PAIN LEVEL: Subjectivecom plaints: improvement exiccrbationofsymptorns improvement [ ] Continued {] PT reports: [ ]no change in symptoms ( ] Slight R Elbow Pain Ç}1w Back Pain . O UR Shoulder Pain [] 1 . [d.NiÍckPain U.Middic Back Pain Patient-c/o : " --- {/R'Ankle Pain [ ] UR FootPairr Pain Ki fPain . Wrist Pain [ ]UR Hip . [ ] US ]0ther O MMS. Weakness O Defom°ty [ ] Trigge poitat Ob jectiveFindings: Muscle.Spasm [-J (,) Tendemess O Tightness []New physicalexain findingsani '-- cliangein physicalfindingssinceinst visit [ ) No Exercisc Therapeutic/ nicalMassage O Myofascial Release [ ] Therapeutic Trea tment Plan Pack t / Cold [.] -' other- ParaffinWax Bath . [] Ultrasound O ] [ ] cc°(iegi/Stiniulation/Tens. treatmentwell Change pan of care Assessment: tolerated Patient [ ] [ · Discharge from the Patient therapy an: - Continue PT mabaq cutgivtin O . Patienb Sigeniture: X (1 f TherapisPs Signaturet mt Ihaverecered the E1Iowingrecateciitby P:7/rl.A). ( 1Certiry -w01d · woderate- Sever pate : . 10 LEVEL: 0 I 2 3 4 5 6 7 8 9 PAIN Subicctivecomplaints: - of c×acerbation symptortis improvement Continued improvement [ ] in gyruptoms ·[ ] Slight O TT reports: '[ ] no chañgc ShoulderPain O UREibow PaiI .. Middle Back Pain [_1Lo¶ Back.Pain [ ] UR Patientc/o: L}Neck Pain D Ankle Pain O UR FootPain E R nec Pain [ ) UR * - . O UR WristPain [ ] UR Hip Pain MMS. Weakacss [ ] Òeformity [ ) Trigger point [ I Other: Objective Findings:[.1Muscic.spasm [.]Teaderness O Tightness [I exam findingsare ]· No'change findings in physical sincelastvisit O New physical [ Exercise Therapeutic Myofascial Release [] Pack DJfferapeutic/ cha icalMassage O Treatment Plan / Cohl other- d Ultrasound Wax Para flin Bath [ ] [ ] Ekctri I Stinfulationffens [ ] 6 treatmentwell [ ]Change pan of care Assessment: Patienttolerated - Dischargethe Patientfromtherapy Plan: Continue PT managpfnent given O w[3 Patient' Signature: X fro Signattere: eceived Elfowing armentby P.T/P.T.A). Therapist's ( I Ccedfythat I have A G. 33ROOKCNN. NY 21sM MODERN IIROOKLYN MEDICAL, PC 1901 NOSTRAND T. At rhysicalThera PW rttyrical Therepintr E s etam FILED: KINGS COUNTY CLERK 07/25/2022 04:37 PM INDEX NO. 509187/2020 NYSCEF DOC. NO. 36 RECEIVED NYSCEF: 07/25/2022 Èhysicar0terapy Progress Notes NAME: Y 7 /L AGE: D.O. A: O PATIENT &C M/S. LIG SPRAIN / STRAIN DIAGNOSIS:_ JVU2 PRECAUTIONS: PHVSICIAN: Omar Ahmed MD Mild Moderate S-:ver Date: LEVEL: 0 I 2- 3 4 5 6 7 S 9 10 SubjecNve complain t: PAIN PT reports: .no changein symptoms impmvement { ] Slight improvement [ ] Continued [ ] exaccrbatioI ofsymptoms [ Back Pain -CEw Back Pain · UR ShoulderPain [] UR Elbow Pain Patientc/o : . ] Nect: Pain []Middle [] AnklePain UR FootPain [ ] UR WristPain [ ·}UR Hip Paid Knec { ] L/R Pain [ ] L/R [} MMS. Weakness Triggerpoim []Oiher: ObicctiveFindings: [ ] Muscle. Spasm[]Tenderness [ J Tightness [} [)Deformity [] since hastvisit New physicatexam lindingsarc [ No cha go in physical findings [] Treatment PInn ‰ot/ Cold Pack · - - 4 Therapeutic/ Mechan Massage Reicase [ J Myofascial [ ] Therapeutic Exercise Bath Ultrasound []othed [ ]ÓectricalStimulationfTens [ ] ParamnWax [] A_ssessmene atient treatment tolerated well [ ]Change pan of-care [ Plan.: PT mimagenient .'ontinue given the Patient f ] Discharge fromtherapy __ [ Patient' Therapist's Signapzre: . Signature: X. . - a nave receivedoic roIrowir,straarme.ni (Iceniry: byP.T/P.T4). ; | - .- -- Mild Moderate Sever Date : PAIN LEVEL: O 1 2.3 4 5 6 7 8 9 10. Subicctive comptaints: improvement Slight Continued improverrient []exacerbationofsymptoms PT reports: [ } no changein symptoms [] [] Pain Shonider Pain [ ] URElbow Pain Patientc/o: - (JNeik Pain []Mi(idicBack Pain t{y-1%GTBack [ ] UR WristPain Pain {]IJA'Koec Pain []·fJR'AnklePain [ ] URFoot Pairl [ ] UR [ )URHip MMS. Weakness []migger poirtt []Other: s Obicctive Findings:I ] Muscle.Spasm [1Tenderness [ ]Tightness [] []Defomúty No cliangein physical findingssincelast visit O New physicalexam findingsare [] Treatmene Plan /Cold Pack 1-)4^herapeutic/ Mecl I Massage Rolcase [ ] Myofascini [ ] Therupcutic Excrcise [ Wax Paraffin Bath . Ultrasound []other: [GJeeti )tiniulatinn/rens. [) [] Assessment: Patienttolerated well treatment Change .[ ] pan of ca.rc . P_[an. ContinuePT man gcmentgiün the i'atient [ ] Discharge fromtherapy £[ ] Patient'siganture:X Therapisi's Signature: rottowingneatmeiitbyP.T/P.T.A).^ that thaverece vedtl e (Icertir . -r Mild Moderate - Sever ... PAINLEVEI2 0 -1 2. 3 4 5 6 7 8 9 10 SubicetWe complaints: ' improvement - [}exacer ätion of symptons PT reports: ]no,change ingyrhptorns [ JSlightimproverpent [) Continued [ M·iddle BackPain ow Back.Pain []UR Shoulder Pain .. []JJR Elbo• Pain . Patientc/o: [QNeck Pain [} Q UR WristPain [ ] UR Hip Pain { J URKnee Pain [] UR Ankle Enin [ ] UllFool;Paiti [] ' [.]Tendcmess Tightiess MMS. Weakness []_eformity []Trigger poiru []Other: Objective Findings: [_] Muscle. Spasm [] [] }·No chan findings in physical since Inst visit [ ]New physicalexam findingsare [ {_].-IfÎerapeutic/ Mcci m lal Massage MyofascialRelease . O TherapputicExercjse Treatment Plan ot)Cold Pack [] Bath' = timulation/Tens ParaffinWax O O7raspund []other L] IcctÓ [) bsgessment: PatienttoFcrated treatment well { }Change pan of care . fContinue PT i a agement givcu [ ] Dischargethe Patient from therapy Plan:_ Patient'Signature: K f ( Therapist's Signature: . that1Imve scccivedthe followinggrcirment (IOcpiry by PT M). FILED: KINGS COUNTY CLERK 07/25/2022 04:37 PM INDEX NO. 509187/2020 NYSCEF DOC. NO. 36 RECEIVED NYSCEF: 07/25/2022 imicalTJierapvProgressNotes PATIENT NA ME: vfr (WS Cú¾ AGE: AS D.O.A: $4 D IAGNOSIS: . Q() M/S. LIG SPRAIN MD' / STRAI - PHYSICIAN: Oma'r Ahmed PRECAUTIONS: Mild Moderate S--ver Date: 0 1 2· 3 4 5 6 7 8. 9 10 Subjective PAIN LEVEL: com pin m is: improvenynt Continued improvement of syrnptoms [ ] exacerbation PT reports: [ ] no ,hange in symptoms [ ] Slight [] Q1.ny Back Pain · UR Shoulder Pain [ J UR Elbow Pain Patientc/o : [Q!feck Pain Middle [ ] Back Pain [} Knee [ ] (JR Pain . [ ] URAnkic Pain [ ] I.JR Foot Pain O UR WristPaih [ -] L/R Hip Paid . [ ] Ttigger-point []Other: Findinps: Obicct.ive [ ] Muscle.Spasm [ ] Tendemess [}Tighmess [ ] MMS. Weakness [ ] Derormity last vjsit physicalexam arc finding;s [ [ No cha iri physicid·findlings since [ j Treatment Pt:in Cold PackA - E-l· lerapeutic/ Mc cal Massage Releas.c - [ ] Myofasci:il Exercise [ ] Therapeutic lßEimulation/Tens ParaffinWex Bath [ ] ·Ultnsound othen. .. [.] h} cu ¤ Assessment:ÊPatient treatment tolerated well [ JChange pan of care from the Patient P_lan Continue-PT agenient given [ ] Discharge therapy aticIttSignature: X O Therapist'sSigns eure: P-TP.T.c). ( I Cenify thit t havereceivedthe followingtecament·by . Mild : Moderate Sever Date : . . PAIN LEVEL: O 1 'i. 3 ..it .5 6 7 8 9 10. Subicctive complainis improvement Continued imprbvement [] cDcerbationofsymptoms PT reports: [ ] no changein symptoms [] Slight [] J.MiddleBack Pain [].hn ack Pain . IJR Shoulder Pàin []UR EÏbow Pain Patient-c/o:- D-]3iecEfain [ [} UT é Pain []·&R'Ankle fain [] R Foot Pain J UR WristPain [] UR Hip Pain [ MMS. Weakness Deformity []Trigg r point []Lther:,: . Obicctive Findings: [ ] Tightness [ Ï} Mkscic. Spasm . .[] Tende ness [] [] []New physicalexam are. findings .. ]No clian9 in physical since findings last visit [ ReIc so - herapeutic.Exercise Treatmeni Plan ]- ol Cold Pack Werapeutic/ Mechani Massage [ ] Myofasciàl [] cr SÈniulation/rens. Wax [ ] Paraffin Bath . [ ]Ultrasound . [ ] other: [ Assessment Patient treatment tolerated Well Change .[ ] pan of care '.lan: ÓontinuePT managem9nt gi tlic l'atient [ ] Discharge from therapy Patient' Thera pis s Signaturia / Siginiture:X . ( I Cersy d arI haven-ceivedthefollowingfreatest by P:rtP.T.A), . Mi d Nfoderate · - Sever Date : . PAIN LEV.EL: 0 I 2. 3 4 5 6 7 8 9 10 Su b jective com plaints: improvement.. on of symptoms [ ] exacerbiit 'PT reports: { 6 chaitgein _yinptoms O Slight improvement [ ] Continued ,[' ShoulderPain UR Elbow Pain .. Patientc/o : ] Neck Pain [ ] Midd te BackPain [ ] LowBack.Pain [] L/R [] Knec Pain UR Ankle Pain . [ ] UR FootPairi [ ] UR WrfstPain [ ] UR Hip Pain [ ] L/R [] - [ ]Tenacmess O Tishtness [ ] MMS.weakness []beformity [ ]fTrigger point [] Other: Ob jective Findings: [. ] Muscie.S pasm " exarn are findings [ Óo change findings in physical v isit since:last [ ] Newphysical V]'Ýherapeutic/Mcch at Massage Release [ ] Myofascial []Tlierapeutic