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PROGNOSIS
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Future Care As Needed?
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Additional information
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GOALS: (content)
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GOALS (achievement timeline): number
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Weeks / Months / Years
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Goals (stabilizing timeline): number
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Weeks / Months / Years
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Next Encounter
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Treatment Outline
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Treatment plan notes
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Soft Tissue Treatment
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Chiropractic Adjustment
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Therapeutic Exercises
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Acupuncture Treatment
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Treatment Notes
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RESTRICTIONS
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Restriction notes
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FUTURE APPT (Core Plan): how many (don't leave blank)
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Week 1
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Week 2
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Week 3
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Week 4
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Week 5
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Week 6
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Week 7
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Week 8
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Week 9
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Week 10
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Week 11
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Week 12
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Week 13
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Week 14
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Week 15
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Week 16
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Core Plan comments
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Low frequency follow-up visits: how many
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weeks to months out
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for HOW MANY TIMES
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or for how many weeks/months?
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weeks to months out
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for HOW MANY TIMES
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or for how many weeks/months?
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weeks to months out
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for HOW MANY TIMES
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or for how many weeks/months?
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weeks to months out
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for HOW MANY TIMES
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or how many weeks/months?
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low frequency follow-up comments
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future appointments
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Exercise Program
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Referrals
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Notes
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