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Comments
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Yoga
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Yoga
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Indications
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Condraindications
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Upper Body Exercises
• • •
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Lower Body Exercises
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Comments
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Duration
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Pilates
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Pilates
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Pre-Pilates/Therapy
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Pre-Pilates/Therapy
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Head Roll Up
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Coccyx Curl
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Hip Bridge/Escalator
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Progressive Breathing
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Thread the Needle
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Cat/Cow
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Knee Sways
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Tow Taps from 90 Degrees
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Puppet Arms
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Side Lying Chest Opener
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Wall Push Ups
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Bird Dog
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Dead Bug
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Band Work
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Foam Roller
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Half Roller Calf Stretch
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Pre-Pilates/Therapy Notes
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Mat
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Mat
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Hundreds
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Roll Up
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Roll Over
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Single Leg Circles
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Rolling Like a Ball
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Five Series
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Single Leg Stretch
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Double Leg Stretch
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Single Straight Leg Stretch/Scissors
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Double Straight Leg Stretch
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Criss Cross
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Spine Stretch Forward
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Open Leg Rocker
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Corkscrew
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Saw
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Mermaid
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Side Kick Series
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Teaser
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Side Lift/Side Plank
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Swan
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Single Leg Kick
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Double Leg Kick
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Neck Pull
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Spine Twist
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Swimming
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Rocking
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Push Ups
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Bridge
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Mat Notes
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Reformer
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Reformer
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Footwork
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Tendon Stretch
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Hundreds
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Leg Circles/Frog
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Pull Straps
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T Pull
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Backstroke
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Teaser
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Short Box Rounded
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Short Box Flat
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Side Bend
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Twist
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Short Box Tree
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Long Stretch
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Down Stretch
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Up Stretch
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Long Stretch Elephant
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Long Stretch Stomach Massage
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Long Stretch Round
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Long Stretch Flat
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Long Stretch Twist
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Knee Stretches
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Running
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Pelvic Lift
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Hip Flexor Stretch
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Reformer Comments
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Cadillac
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Cadillac
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Push Through Forward
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Push Through Backward
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1 Arm Stretch
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Rolling Back 2 Arms
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Rolling Back w/Stretch
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Breathing w/Trapeze
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Leg Springs
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Arm Springs
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On Mat
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Standing
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Manual Stretch
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Cadillac Comments
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Manual Stretch
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Wunda Chair
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Wunda Chair
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Footwork
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Tendon (Calf) Stretch
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Going Up Front
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Going Up Side
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Spine Stretch Forward
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Swan
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Tricep Press
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Press Up Front
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Press Up Back
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Wunda Chair Comments
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Large Barrel
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Large Barrel
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Ballet Stretch Front
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Ballet Stretch Side
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Ballet Stretch Back
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Swan
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Short Box Round
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Short Box Flat
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Short Box Side Bend
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Short Box Tree
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Short Box Twist
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Large Barrel Comments
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Small Barrel
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Small Barrel
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Leg Series
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Arm Series
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Small Barrel Comments
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Spine Corrector
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Spine Corrector
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Stretch Over the Barrel
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Arm Circles
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Leg Series
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Spine Corrector Comments
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Duration
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GYROTONIC
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GYROTONIC
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Pulley Tower
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Pulley Tower
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Arch/Curl
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Hamstring Series
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Upper Body Opening
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Seated Leg Work
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Seated Upper Body Work
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Pulley Tower Comments
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Jump Stretch Board
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Jump Stretch Board
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Arch-Curls
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Standing Leg Work
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Core/Footwork
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Dips/Push Ups
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Skates
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Disc Work
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Jumping
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Jump Stretch Board Comments
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Duration
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Acupuncture
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Acupuncture
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First Set Left Points/Minutes
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Details
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E-stim
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First Set Right Points/Minutes
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Details
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E-stim
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First Set Bilateral Points/Minutes
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Details
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E-stim
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Second Set Left Points/Minutes
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Details
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E-stim
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Second Set Right Points/Minutes
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Details
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E-stim
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Second Set Bilateral Points/Minutes
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Details
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E-stim
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Third Set Left Points/Minutes
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Details
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E-stim
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Third Set Right Points/Minutes
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Details
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E-stim
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Third Set Bilateral Points/Minutes
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Details
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E-stim
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Infrared
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Infrared time
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Manual Therapy
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Manual Therapy time
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Cupping
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Cupping time
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Acupunture Comments
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Treatment
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Treatment Frequency week:
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Treatment Frequency Weeks:
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Re-examination:
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Chiropractic Adjustments 98940
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Extraspinal Adjustments 98943
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Therapeutic Exercise 97110 59
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Electrical Stim Attended 97032
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Manual Therapy Techniques 97140
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Cold/Hot Pack 97010
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Neuromuscular Re-Ed 97112 59
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Ultrasound Therapy 97035
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Mechanical Traction (Spinal Decompression) 97012
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Records reviewed
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Treatment Duration week
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Treatment Duration Month
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Comments
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Radiology
• • •
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Laboratory
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Labs
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Lab Comments
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Radiology
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Radiology Comments
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PT Recommendations
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PT Recommendation Comments
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Home Health
• • •
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Home health comments
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Referrals
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Referral Comments
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Education
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Education Comments
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Diet
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Diet Comments
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General Instructions
• • •
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General Instruction Comments
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Treatment Plan
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Current functional status/major problems
• • •
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Long term goals : 12 visits
• • •
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Short term goals :6 visits
• • •
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If other , specify
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