|
Acknowledgement of Services (Required)
|
|
|
|
|
|
SUBJECTIVE
|
|
|
OBJECTIVE
|
|
|
|
|
|
Procedures Performed
|
|
|
Manipulations/Mobilizations
|
|
|
Cervical/Head
• • •
|
Manipulation or Mobilization
|
|
Thoracic
• • •
|
Manipulation or Mobilization
|
|
Lumbar
• • •
|
Manipulation or Mobilization
|
|
Sacrum
• • •
|
Manipulation or Mobilization
|
|
Pelvis
• • •
|
Manipulation or Mobilization
|
|
Lower Extremity
• • •
|
Manipulation or Mobilization
|
|
Upper Extremity
• • •
|
Manipulation or Mobilization
|
|
Other
|
Comments
|
|
Soft Tissue Mobilization
|
|
|
Head/Neck/Upper Back
• • •
|
Mid Back
• • •
|
|
Low Back/Pelvis
• • •
|
Hip
• • •
|
|
Knee
• • •
|
Ankle/Foot
• • •
|
|
Shoulder
• • •
|
Elbow
• • •
|
|
Wrist/Hand
• • •
|
Other
|
|
Comments
|
|
|
Soft Tissue Compliance Restoration
|
|
|
Head/Neck/Upper Back
• • •
|
Mid Back
• • •
|
|
Low Back/Pelvis
• • •
|
Hip
• • •
|
|
Knee
• • •
|
Ankle/Foot
• • •
|
|
Shoulder
• • •
|
Elbow
• • •
|
|
Wrist/Hand
• • •
|
Other
|
|
Comments
|
|
|
Manually Resisted Therapeutic Exercise
|
|
|
Neck
• • •
|
Trunk
• • •
|
|
Hip w/ Straight Leg
• • •
|
Hip w/ Knee Bent
• • •
|
|
Knee
• • •
|
Ankle
• • •
|
|
1st MTP
• • •
|
Shoulder
• • •
|
|
Elbow
• • •
|
Wrist
• • •
|
|
Other
|
Comments
|
|
|
|
|
Other procedures performed? List here
|
|
|
Providers Involved in Today's Tx (Required)
|
|
|
|
|
|
ASSESSMENT
|
|
|
Patient responded well to care?
|
No? Explanation Required
|
|
Additional Information
|
|
|
|
|
|
PLAN
|
|
|
Patient to be seen on as needed basis?
|
Other Plan?
|
|
Additional Information
|
|
