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THERAPIST NAME:
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PROVIDER NAME:
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History per patient:
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Pain Intensity
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Personal Care Limitations
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Lifting Limitations
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Reading Limitations
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Headache scale
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Concentration scale
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Work Limitations
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Driving
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PHYSICAL EXAMINATION
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THERAPIST EXAM FINDINGS
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BODY DIAGRAM
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PROVIDER EXAM FREE TEXT:
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MUSCLES
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JOINTS ANATOMY
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ASSESSMENT
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PROVIDER ASSESSMENT:
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THERAPIST ASSESSMENT:
• • •
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Joint Mobilization Therapy
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Name of Joint/Number of reps.
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Mobilization Grade
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Name of Joint/Number of reps.
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Mobilization Grade
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Name of Joint/Number of reps.
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Mobilization Grade
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Name of Joint/Number of reps.
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Mobilization Grade
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Massage Therapy
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Neck Area:
• • •
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Massage therapy type
• • •
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Duration of therapy:
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Back Area:
• • •
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Massage therapy type
• • •
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Duration of therapy:
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Chest Area:
• • •
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Massage therapy type
• • •
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Duration of therapy:
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Upper Extremity Area:
• • •
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Massage therapy type
• • •
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Duration of therapy:
|
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Lower Extremity Area:
• • •
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Massage therapy type
• • •
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Duration of therapy:
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Name of therapist for signature:
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SIGNATURE
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