Client Name:
Date:
Identify CURRENT symptomatic areas in your body by drawing the appropriate symbols on the figures below.
Circle areas of PAIN
"X" over areas of JOINT AND MUSCLE STIFFNESS
Draw wavy lines along the areas of NUMBNESS OR TINGLING
Mark RECENT SCARS, BRUISES or OPEN WOUNDS
How I feel today:
* For Office Use Only *
Back / Posterior Shoulder:
Erector Spinae
Infraspinatus
Latissimus Dorsi
Psoas
Quadratus Lumborum
Rhomboids
Serratus Anterior
Subscapularis
Supraspinatus
Teres Minor / Minor
Trapezius, Upper
Trapezius, Lower
Triceps
L
L
L
L
L
L
L
L
L
L
L
L
L
R
R
R
R
R
R
R
R
R
R
R
R
R
B
B
B
B
B
B
B
B
B
B
B
B
B
TP
TP
TP
TP
TP
TP
TP
TP
TP
TP
TP
TP
TP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
Neck / Head:
Levator Scapulae
Masseter
Scalenes (Ant-Med-Post)
Splenius Capitis
Splenius Cervices
Sternocleidomastoid
Suboccipitals
Temporalis
L
L
L
L
L
L
L
L
R
R
R
R
R
R
R
R
B
B
B
B
B
B
B
B
TP
TP
TP
TP
TP
TP
TP
TP
SP
SP
SP
SP
SP
SP
SP
SP
Legend:
L = Left
R = Right
Notes:
B = Bilateral
TP = Trigger Point
SP = Spasm
Subjective:
Leg:
Adductors (upper - lower)
Biceps Femoris
Gastrocnemius
Peroneus Longus/Brevis
Quadriceps Femoris Group
Sartorius
Soleus
Tensor Facia Latae
Tibialis Anterior
L
L
L
L
L
L
L
L
L
R
R
R
R
R
R
R
R
R
B
B
B
B
B
B
B
B
B
TP SP
TP SP
TP SP
TP SP
TP SP
TP SP
TP SP
TP SP
TP SP
Arm:
Biceps Brachii
Deltoid
Extensor Group
Flexor Group
Triceps Brachii
L
L
L
L
L
R
R
R
R
R
B
B
B
B
B
TP
TP
TP
TP
TP
SP
SP
SP
SP
SP
Co-Pay Received?
Hip:
Gluteus Maximus
Gluteus Med/Min.
Illiacus
Piriformis
L
L
L
L
Chest:
Intercostals
Pectoralis Major
L R B TP SP
L R B TP SP
R
R
R
R
B
B
B
B
TP
TP
TP
TP
SP
SP
SP
SP
$
CPT Treatment
Codes for Today:
Yes - No: 97010 Hot/Cold
____qty: 97112
Neuromuscular
Reeducation
15min
____qty: 97124 Massage 15min
Yes - No: 97250 Myofacial Release
Therapist Initials: