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PROCEDURES
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MANIPULATIONS/MOBILIZATIONS
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Cervical/Head
• • •
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Manipulation or Mobilization
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Thoracic
• • •
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Manipulation or Mobilization
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Lumbar
• • •
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Manipulation or Mobilization
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Sacrum
• • •
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Manipulation or Mobilization
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Pelvis
• • •
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Manipulation or Mobilization
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Lower Extremity
• • •
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Manipulation or Mobilization
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Upper Extremity
• • •
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Manipulation or Mobilization
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Other
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Time
• • •
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Notes
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TRANSVERSE FRICTION MASSAGE (97140)
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Head/Neck/Upper Back
• • •
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Mid Back
• • •
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Low Back/Pelvis
• • •
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Hip
• • •
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Knee
• • •
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Ankle/Foot
• • •
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Shoulder
• • •
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Elbow
• • •
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Wrist/Hand
• • •
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Other
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Time
• • •
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Notes
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TISSUE COMPLIANCE RESTORATION (97140)
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Head/Neck/Upper Back
• • •
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Mid Back
• • •
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Low Back/Pelvis
• • •
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Hip
• • •
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Knee
• • •
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Ankle/Foot
• • •
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Shoulder
• • •
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Elbow
• • •
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Wrist/Hand
• • •
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Other
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Time
• • •
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Notes
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OTHER MANUAL THERAPIES (97140)
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List Area & Technique
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Time
• • •
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Notes
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NEUROMUSCULAR RE-EDUCATION (97112)
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Neck
• • •
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Trunk
• • •
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Hip w/ Straight Leg
• • •
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Hip w/ Knee Bent
• • •
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Knee
• • •
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Ankle
• • •
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1st MTP
• • •
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Shoulder
• • •
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Elbow
• • •
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Wrist
• • •
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Other
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Time
• • •
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Notes
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MANUALLY RESISTED THER. EX. (97110)
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Neck
• • •
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Trunk
• • •
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Hip w/ Straight Leg
• • •
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Hip w/ Knee Bent
• • •
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Knee
• • •
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Ankle
• • •
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1st MTP
• • •
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Shoulder
• • •
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Elbow
• • •
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Wrist
• • •
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Other
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Time
• • •
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Notes
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THERAPEUTIC EXERCISES (97110)
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Exercise #1
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Parameters (sets/reps/weight) & Comments
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Exercise #2
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Parameters (sets/reps/weight) & Comments
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Exercise #3
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Parameters (sets/reps/weight) & Comments
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Exercise #4
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Parameters (sets/reps/weight) & Comments
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Exercise #5
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Parameters (sets/reps/weight) & Comments
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Exercise #6
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Parameters (sets/reps/weight) & Comments
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Exercise #7
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Parameters (sets/reps/weight) & Comments
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Exercise #8
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Parameters (sets/reps/weight) & Comments
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Other
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Time
• • •
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Notes
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THERAPEUTIC ACTIVITIES (97530)
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Activity #1
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Parameters (sets/reps/weight) & Comments
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Activity #2
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Parameters (sets/reps/weight) & Comments
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Activity #3
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Parameters (sets/reps/weight) & Comments
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Activity #4
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Parameters (sets/reps/weight) & Comments
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Activity #5
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Parameters (sets/reps/weight) & Comments
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Activity #6
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Parameters (sets/reps/weight) & Comments
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Activity #7
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Parameters (sets/reps/weight) & Comments
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Activity #8
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Parameters (sets/reps/weight) & Comments
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Other
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Time
• • •
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Notes
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HOME EXERCISE PROGRAM
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HEP
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Time
• • •
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Notes
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MODALITIES
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List Modalities & Parameters
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Time
• • •
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Notes
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GAIT TRAINING (97116)
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Please list procedures performed here:
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Time
• • •
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Notes
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