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SUBJECTIVE
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Chief Complaint
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Area(s) of Pain
• • •
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Onset
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Level of Pain (10 highest and 1 lowest)
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Radiation
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Timing
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Patient's Weight
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Patient's Height
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Numbness
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Tingling
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How Does Patient Feel About Their Weight?
• • •
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Patient's Sleep
• • •
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Patient Headaches
• • •
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Patient's Level of Anxiety
• • •
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Patient's Bowel Movements
• • •
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Notes
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OBJECTIVE
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Patient's Apparent Health / Status
• • •
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Patient Progression Toward Goals
• • •
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Areas of Sensitivity
• • •
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New Problem
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Notes
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ASSESSMENT
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Diagnosis
• • •
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Was this an initial OFFICE visit?
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Was this an established OFFICE visit?
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Was this an initial HOME visit?
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Was this an established HOME visit?
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Was this an Acupuncture Session?
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Was this a Physical Therapy Session?
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Was this a Chiropractic Session?
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Was this a Myofascial Release/Massage?
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Was this a PT (Yoga Session)?
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Was this a PT (Pilates Session)?
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Did You Use E. Stim?
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How Many Units Were Used?
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Did You Use Ultrasound?
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How Many Units Were Used?
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Did You Use Hot or Cold Packs?
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Did You Use Traction?
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Human Body
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Has the patient shown improvement?
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Notes
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PLAN
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Is the treatment plan still in progress?
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Referrals / Recomendations
• • •
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Is the treatment plan complete?
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Notes
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