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Consent Given?
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Using sterile technique, antiseptic solution was used to prepare the area to be treated, the following procedures were performed
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Intra-lesional Injections (11900)
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Tender, hypertrophic scars were infiltrated with Neural Therapy technique
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1. Side
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Volume
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of 1/2 % Procaine solution infiltrated to ___
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Comments
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2. Side
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Volume
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of 1/2 % Procaine solution infiltrated to ___
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Comments
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3. Side
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Volume
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of 1/2 % Procaine solution infiltrated to ___
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Comments
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4. Side
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Volume
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of 1/2 % Procaine solution infiltrated to ___
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Comments
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5. Side
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Volume
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of 1/2 % Procaine solution infiltrated to ___
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Comments
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Hemostasis obtained post-treatment and no complications observed
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Prolotherapy/Prolozone (M0076)
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Ligaments/Tendons noted below were found to be tender and reproduced the patient’s pain pattern
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1. Side
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0.5 cc of ___
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With (ozone)
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0.5 cc of O3 ___
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injected to ____(Tendon List)
• • •
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Without
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injected to ____(Tendon List)
• • •
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Comments
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2. Side
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0.5 cc of ___
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With (ozone)
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0.5 cc of O3 ___
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injected to ____(Tendon List)
• • •
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Without
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injected to ____(Tendon List)
• • •
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Comments
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3. Side
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0.5 cc of ___
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With (ozone)
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0.5 cc of O3 ___
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injected to ____(Tendon List)
• • •
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Without
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injected to ____(Tendon List)
• • •
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Comments
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Hemostasis obtained post-treatment and no complications observed
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Intra-articular Injections
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1. Side
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Region
• • •
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was/were injected using solution of ____
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1/2% Procaine D15% / D25%
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With
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1cc/2.5cc/5cc of O3
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11gamma/15gamma/45gamma
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2. Side
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Region
• • •
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was/were injected using solution of ____
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1/2% Procaine D15% / D25%
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With
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1cc/2.5cc/5cc of O3
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11gamma/15gamma/45gamma
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3. Side
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Region
• • •
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was/were injected using solution of ____
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1/2% Procaine D15% / D25%
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With
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1cc/2.5cc/5cc of O3
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11gamma/15gamma/45gamma
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4. Side
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Region
• • •
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was/were injected using solution of ____
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1/2% Procaine D15% / D25%
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With
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1cc/2.5cc/5cc of O3
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11gamma/15gamma/45gamma
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5. Side
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Region
• • •
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was/were injected using solution of ____
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1/2% Procaine D15% / D25%
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With
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1cc/2.5cc/5cc of O3
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11gamma/15gamma/45gamma
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Hemostasis obtained post-treatment and no complications observed
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Biopuncture
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1. Side
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___ of 1/2% Procaine solution
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Total Body
• • •
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Tendon List
• • •
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Comments
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2. Side
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___ of 1/2% Procaine solution
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Total Body
• • •
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Tendon List
• • •
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Comments
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3. Side
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___ of 1/2% Procaine solution
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Total Body
• • •
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Tendon List
• • •
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Comments
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4. Side
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___ of 1/2% Procaine solution
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Total Body
• • •
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Tendon List
• • •
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Comments
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5. Side
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___ of 1/2% Procaine solution
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Total Body
• • •
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Tendon List
• • •
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Comments
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Hemostasis obtained post-treatment and no complications observed
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Acupuncture
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1. Side
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Total Body
• • •
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Tendon List
• • •
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Comments
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electro/stimulated with ___
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2. Side
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Total Body
• • •
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Tendon List
• • •
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Comments
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electro/stimulated with ___
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3. Side
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Total Body
• • •
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Tendon List
• • •
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Comments
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electro/stimulated with ___
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4. Side
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Total Body
• • •
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Tendon List
• • •
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Comments
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Electro Acupuncture
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electro/stimulated with ___
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5. Side
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Total Body
• • •
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Extraordinary
• • •
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Tendon List
• • •
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Comments
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Electro Acupuncture
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electro/stimulated with ___
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Hemostasis obtained post-treatment and no complications observed
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Acupuncture Ion-Pumping Cords
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Side
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BL (60/62)
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SI (3/11)
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Up or Down
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Side
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TH (5/8)
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GB (34/41)
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Up or Down
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(Side) SP6 to LI11
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Up or Down
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(Side) KI3 to Anterior Adrenal Points
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Up or Down
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Side
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Comments
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Side
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Comments
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Free Text
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Free Text
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Free Text
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Hemostasis obtained post-treatment and no complications observed
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Auricular Acupuncture
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1. Side
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Comments
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2. Side
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Comments
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3. Side
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Comments
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4. Side
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Comments
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5. Side
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Comments
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6. Side
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Comments
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7. Side
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Comments
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8. Side
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Comments
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9. Side
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Comments
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10. Side
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Comments
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Hemostasis obtained post-treatment and no complications observed
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Scalp Acupuncture
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1. Side
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Comments
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2. Side
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Comments
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3. Side
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Comments
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4. Side
|
Comments
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5. Side
|
Comments
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Hemostasis obtained post-treatment and no complications observed
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Laser
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TENCAM 18” from the body, 10 sec to each
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Total Body
• • •
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Tendon List
• • •
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Comments
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Free Text
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