|
CONTRAINDICATION checked?
|
Contraindication list
• • •
|
|
Notes on Contraindication
|
OUTCOME Assessment
|
|
Outcome questionnaires
• • •
|
Outcome score(s)
|
|
SOAP
|
|
|
Massages
|
Chiro / No ART
|
|
Subj - ART, no Chiro (e.g. ART massage)
|
Subjective - Chiro, no ART
|
|
Subj - soft tissue /no ART no Chiro (massage)
|
Subjective - blank
|
|
Chiro + ART
|
Chiro + Myofascial
|
|
Subjective - ART
|
Subjective - Myofascial
|
|
Pain Level
|
Pain Location
|
|
ROM
|
Ortho, Palp and other tests
|
|
Gait, Posture, Movement
|
IASTM / Fascial Abrasion Tool Tx
|
|
ART Tx
|
Myofascial Tx
|
|
Laterality - DO NOT LEAVE BLANK!!
|
Adhesions
|
|
Laterality
|
Adhesions
|
|
Laterality
|
Adhesions
|
|
Laterality
|
Adhesions
|
|
Laterality - Myofasical
|
Adhesions - Myofasical
|
|
Laterality - Myofasical
|
Adhesions - Myofasical
|
|
Laterality - Myofasical
|
Adhesions - Myofasical
|
|
ART Nerve Protocols
|
Long Tract Nerve - Myofascial
• • •
|
|
Long Tract Nerves & related Local/Terminal Nerves - ART
• • •
|
Non-long Tract Trunk Nerves - ART
• • •
|
|
Nerve Protocol Treatment Notes
|
|
|
ART treatment highlights
|
Myofascial treatment highlights
|
|
Treatment Notes
|
Plan for future treatment
|
|
Chiropractic Adjustment
|
|
|
C/S adjustment
|
|
|
Cervical Adjustments
• • •
|
Cervical Comments
|
|
T/S adjustment
|
|
|
Thoracic Adjustments
• • •
|
Thoracic Comments
|
|
L/S adjustment
|
|
|
Lumbar Adjustments
• • •
|
Lumbar Comments
|
|
Extremity adjustment
|
|
|
Extremity Adjustments
• • •
|
Extremity Comments
|
|
PEMF
|
|
|
PEMF Frequency
|
PEMF Intensity
|
|
PEMF time
|
PEMF structure
|
|
PEMF-2 Frequency
|
PEMF Intensity
|
|
PEMF time
|
PEMF structure
|
|
Other Treatment 1
|
Other Treatment 2
|
|
Massage Notes
|
|
|
Treatment Response
|
Treatment Notes
|
|
Exercises
|
Exercise notes
|
|
Stretching Exercises
|
|
|
Stretching Exercises UE
• • •
|
Exercise notes
|
|
Stretching Exercises LE
• • •
|
Exercise notes
|
|
Stabilizing, Strengthening, Coordination, or Performance
|
|
|
Core & Trunk Exercises
• • •
|
Exercise notes
|
|
Upper Extremity Exercises
• • •
|
Exercise notes
|
|
Lower Extremity Exercises
• • •
|
Exercise notes
|
|
Gait Exercises (Running included)
• • •
|
Exercise notes
|
|
Integrated Exercises
• • •
|
Exercise notes
|
|
|
Total Exercise time
|
|
Treatment Notes
|
|
