Plan Of Care Form

Name*

Date*

Treatment Goals*

Prognosis*

Excellent: Uncomplicated case with continuing improvement expected and permanent residuals not expected

Good: Complicated case with continuing improvement expected and permanent residuals possible

Fair: Complicated case with continuing improvement expected and permanent residuals probable

Frequency of Visits

Times Per Week

For Number of Weeks

Re-evaluation

Re-evaluate

in Weeks

Refer to

Physician

Procedures and Treatment

Sarapin Trigger Point Injections

Times Per Week

For Number of Weeks

Joint Injections

Amniotic Tissue Allograft (Stem Cells)

PRP

Area

Peripheral Neuropathy Protocol

Upper Extremity

Lower Extremity

Weight Management

Medical Weight Loss Program (Based on Laboratory Tests)

Natural Weight Loss Program

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Plan of Care Form