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Complaint#1
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Pain Severity on a [1-10] scale is
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Complaint#2
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Pain Severity on a [1-10] scale is
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New Complaint
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Pain Severity on a [1-10] scale is
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C1-% of time do you have pain in a 24 hr period?
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C2-% of time do you have pain in a 24 hr period?
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C3-% of time do you have pain in a 24 hr period?
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Human body diagram
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Since the injury, has your condition
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Describe the type of pain-what does it feel like
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If other_____
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Activities/movements that are painful to perform
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If other_____
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Does your pain interfere with your_____
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If other_____
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Cervical
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Shoulder
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Trapezius
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Thoracic
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Chest
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Ribs
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Abdomen
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Biceps
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Triceps
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Pectorals
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Limb
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Elbow
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Wrist
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Lumbar
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Hand
• • •
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Fingers/Toes
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Sacroiliac
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Quadriceps
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Ham Strings
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Sciatic
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Hips/pelvis
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Knee
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Ankle
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Foot
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Other
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Other
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Other
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Other
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PULSE
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TONGUE
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Pls go to H&P/SOAP to enter ICD codes
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Continuation of same w/
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Prognosis
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PHYSICIANS NOTES ON PATIENT
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1. ____
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2. ____
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3. ____
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PLAN
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TODAY’S TREATMENT & THERAPIES
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Acupuncture Treatment: with multiple reinsertion
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Acupuncture Point Prescription:
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1. ____
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2. ____
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3. ____
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1.Acupressure to the following segments/regions:
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2. Manual Therapy to following segments/regions
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3. Myofascial release and positional release:
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4. Mobilization/gliding:
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5. Therapeutic stretching:
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6. Trigger Point Therapy to the following region
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7.Discussed/reviewed to strengthen/reduce pain
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8.Discussed/reviewed to strengthen/reduce pain
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9.Discussed/reviewed to strengthen/reduce pain
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POST TREATMENT SUBJECTIVE PATIENT STATEMENT
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LOCATION OF PAIN
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SEVERITY
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ROM has improved by ____%
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on________
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ROM has improved by ____%
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on________
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ROM has improved by ____%
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on________
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PHYSICIANS PROGNOSIS ON PATIENT CONDITIONS
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Today’s Response to the treatment was
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Patient Progress is____
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Patient currently being seen:
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If other
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