Patient's Name:                                                                                                                 File#

KEY to S.O.A.P. notes Cervical/Thoracic/Lumbar; Improved/Same/Worse/Resolved; Slight/Mild/Moderate/Severe
Pain Areas: Cervical, Thoracic, Lumbar, Pelvic, Extremity, Wrist, Shoulder
Muscle groups: Paraspinal, trapezus, deltoid, levator scapulae, rhomboid, quadratus lumborum, hamstrings, calf muscle group, right and left sided Sciatica / Subluxation - Occ. to Sacrum; Range of Motion - Adjust Areas;
Pelvic Deficiency (leg length) P.T. Modalities: Ultrasound, MyoPulse, Interferential, Massage, Heat, Exercise Used 
by permission, D.C. Vacation Relief 1(800)797-2457 www.drbackman.com

DATE

DATE

C- I. S. W. R      Si Mi M S   
T- I. S. W. R.     Si Mi M S   
L- I. S. W. R.     Si Mi M S
Ex-I. S. W. R      Si Mi M S 
Pain Area: C, T, L, P, Ex, Wr, Sho, Thigh-ham./quad. Knee, Forearm
Muscle Groups: Paraspinal C T L. Trap, Delt, Lev-Scap, Rhom, Quad.Lumb Quad, Ham, Calf, Lt-Rt Sciatica
Sublux.O1234567-123456789101112-12345-S
Disability Status:  Yes  No  
             With--Without Limitations
R.o.M.  C ­ ¯  T ­ ¯  L ­ ¯  Ex ­ ¯    
Adjust  O – C – T – L - S/P - Ex
P.D.  right. - left
Modalities: Ultra, Myo, Inf, Mass, Heat, Exer.

C- I. S. W. R      Si Mi M S   
T- I. S. W. R.     Si Mi M S   
L- I. S. W. R.     Si Mi M S
Ex-I. S. W. R      Si Mi M S 
Pain Area: C, T, L, P, Ex, Wr, Sho, Thigh-ham./quad. Knee, Forearm
Muscle Groups: Paraspinal C T L. Trap, Delt, Lev-Scap, Rhom, Quad.Lumb Quad, Ham, Calf, Lt-Rt Sciatica
Sublux.O1234567-123456789101112-12345-S
Disability Status:  Yes  No  
             With--Without Limitations
R.o.M.  C ­ ¯  T ­ ¯  L ­ ¯  Ex ­ ¯    
Adjust  O – C – T – L - S/P - Ex
P.D.  right. - left
Modalities: Ultra, Myo, Inf, Mass, Heat, Exer.

DATE

DATE

C- I. S. W. R      Si Mi M S   
T- I. S. W. R.     Si Mi M S   
L- I. S. W. R.     Si Mi M S
Ex-I. S. W. R      Si Mi M S 
Pain Area: C, T, L, P, Ex, Wr, Sho, Thigh-ham./quad. Knee, Forearm
Muscle Groups: Paraspinal C T L. Trap, Delt, Lev-Scap, Rhom, Quad.Lumb Quad, Ham, Calf, Lt-Rt Sciatica
Sublux.O1234567-123456789101112-12345-S
Disability Status:  Yes  No  
             With--Without Limitations
R.o.M.  C ­ ¯  T ­ ¯  L ­ ¯  Ex ­ ¯    
Adjust  O – C – T – L - S/P - Ex
P.D.  right. - left
Modalities: Ultra, Myo, Inf, Mass, Heat, Exer.

C- I. S. W. R      Si Mi M S   
T- I. S. W. R.     Si Mi M S   
L- I. S. W. R.     Si Mi M S
Ex-I. S. W. R      Si Mi M S 
Pain Area: C, T, L, P, Ex, Wr, Sho, Thigh-ham./quad. Knee, Forearm
Muscle Groups: Paraspinal C T L. Trap, Delt, Lev-Scap, Rhom, Quad.Lumb Quad, Ham, Calf, Lt-Rt Sciatica
Sublux.O1234567-123456789101112-12345-S
Disability Status:  Yes  No  
             With--Without Limitations
R.o.M.  C ­ ¯  T ­ ¯  L ­ ¯  Ex ­ ¯    
Adjust  O – C – T – L - S/P - Ex
P.D.  right. - left
Modalities: Ultra, Myo, Inf, Mass, Heat, Exer.

DATE

DATE

C- I. S. W. R      Si Mi M S   
T- I. S. W. R.     Si Mi M S   
L- I. S. W. R.     Si Mi M S
Ex-I. S. W. R      Si Mi M S 
Pain Area: C, T, L, P, Ex, Wr, Sho, Thigh-ham./quad. Knee, Forearm
Muscle Groups: Paraspinal C T L. Trap, Delt, Lev-Scap, Rhom, Quad.Lumb Quad, Ham, Calf, Lt-Rt Sciatica
Sublux.O1234567-123456789101112-12345-S
Disability Status:  Yes  No  
             With--Without Limitations
R.o.M.  C ­ ¯  T ­ ¯  L ­ ¯  Ex ­ ¯    
Adjust  O – C – T – L - S/P - Ex
P.D.  right. - left
Modalities: Ultra, Myo, Inf, Mass, Heat, Exer.

C- I. S. W. R      Si Mi M S   
T- I. S. W. R.     Si Mi M S   
L- I. S. W. R.     Si Mi M S
Ex-I. S. W. R      Si Mi M S 
Pain Area: C, T, L, P, Ex, Wr, Sho, Thigh-ham./quad. Knee, Forearm
Muscle Groups: Paraspinal C T L. Trap, Delt, Lev-Scap, Rhom, Quad.Lumb Quad, Ham, Calf, Lt-Rt Sciatica
Sublux.O1234567-123456789101112-12345-S
Disability Status:  Yes  No  
             With--Without Limitations
R.o.M.  C ­ ¯  T ­ ¯  L ­ ¯  Ex ­ ¯    
Adjust  O – C – T – L - S/P - Ex
P.D.  right. - left
Modalities: Ultra, Myo, Inf, Mass, Heat, Exer.