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CONTRAINDICATION checked?
Contraindication list
• • •
Notes on Contraindication
OUTCOME Assessment
Outcome questionnaires
• • •
Outcome score(s)
SOAP
PHYSICAL MEDICINE
Subj - ART, no Chiro
Subj - soft tissue /no ART no Chiro
CHIROPRACTIC
Chiro + ART
Chiro + Myofascial
Subjective - ART
Subjective - Myofascial
Chiro / No ART
Subjective - Chiro, no ART
Subjective - blank
Pain Level
Pain Location
Notes on Objective
Notes on Assessment
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
Alternative Chiro Adj
Alternative C/S adj
Alternative Cervical Adj levels
• • •
Alternative Cervical Comments
Alternative T/S adj
Alternative Thoracic Adj levels
• • •
Alternative Thoracic Comments
Alternative L/S adj
Alternative Lumbar Adj levels
• • •
Alternative Lumbar Comments
Alternative Extremity adj
Alternative Extremity Adj levels
• • •
Alternative Extremity Comments
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 Frequency
PEMF Intensity
PEMF time
PEMF structure
Other Treatment 1
Other Treatment 2
Massage Notes
Treatment Response
Treatment Notes
Exercises (narrative only)
Exercises (narrative only)
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
Future Treatment planning

Travel Card (Revision 4) Medical Form

Chiropractor

APC Travel card (SOAP)

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Published: June 6, 2024, 3:08 a.m.
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