|
Diagnosis
|
Prescription Expiration
|
|
Site
|
Quality
• • •
|
|
|
|
|
Intensity
|
Patient Specific Functional Scale:
|
|
Head Tensions
• • •
|
TPs:
• • •
|
|
Modalities
• • •
|
Adhesions
• • •
|
|
Other Head Notes:
|
Duration
|
|
Neck Tensions:
• • •
|
TPs:
• • •
|
|
Modalities
• • •
|
Adhesions
• • •
|
|
Other Neck Notes:
|
Duration
|
|
|
|
|
Shoulder Tensions:
• • •
|
TPs:
• • •
|
|
Modalities
• • •
|
Adhesions
• • •
|
|
Other Shoulder Notes:
|
Duration
|
|
|
|
|
Back Tensions
• • •
|
TPs
• • •
|
|
Modalities
• • •
|
Adhesions
• • •
|
|
Other Back Notes:
|
Duration
|
|
|
|
|
Upper Extremity Tensions
• • •
|
TPs:
• • •
|
|
Modalities
• • •
|
Adhesions
• • •
|
|
Other Upper Extremity Notes:
|
Duration
|
|
|
|
|
Lower Body Tensions
• • •
|
TPs:
• • •
|
|
Modalities
• • •
|
Adhesions
• • •
|
|
Other Lower Body Notes:
|
Duration
|
