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Reason for Visit:
Reason for Visit
DOA
SUBJECTIVE:
Comments:
OBJECTIVE:
Comments:
ASSESSMENT
• • •
Comments:
Continue Prescribed Treatment Plan
Treatment:
99212: OUTPATIENT VISIT EST
• • •
Chiropractic Adjustments 98940
• • •
Chiropractic Adjustments 98941
• • •
Chiropractic Adjustments 98942
• • •
Extraspinal Adjustments 98943
• • •
Activator Technique
• • •
Man. Therapy (97140) Technique
• • •
Technique Notes
Unit
Region
• • •
Start time
End time
ADL Self Care(97535)
Notes
Unit
Start time
End time
Region
• • •
Ultrasound(97035)
Notes
Unit
Start time
End time
Region
• • •
EMS(G0283)
Notes
Unit
Start time
End time
Region
• • •
Traction(97012)
Notes
Unit
Start time
End time
Region
• • •
Hot/Cold(97010)
Notes
Unit
Start time
End time
Region
• • •
(NMR) Neuro-Muscular Re-Education(97112)
• • •
Notes
Unit
Start time
End time
Region
• • •
Therapeutic Exercises(97110)
• • •
Notes
Unit
Region
• • •
Start time
End time
Therapeutic Activities 97530:
• • •
Notes
Unit
Region
• • •
Start time
End time
Patient Signature
PATIENT SIGNATURE
CONFIRMATION
Modify Frequency to
Modify Length of Frequency to
Provider notes

Chiropractic Daily Note Cape Coral (Dr. Sikkema) Medical Form

Family Practitioner

Chiropractic Daily Note Cape Coral (Dr. Sikkema)

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Published: March 5, 2021, 10:09 p.m.
Doctor: Dr. History Physical
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