Name
Complaint history
Pain Level 0 = no Pain 10 = extreme pain
10
9
8
7
6
5
4
3
2
1
0
Visit 1
Visit 2
Visit 3
Visit 4
Visit 5
Complaint frequency
Constant
Frequent
Intermittent
Occasional
Resolved
Visit 1
Visit 2
Visit 3
Visit 4
Visit 5
Procedures performed
Laser
Manipulation
Electric Stim
Traction
Soft Tissue
Exercises
Visit 1
Visit 2
Visit 3
Visit 4
Visit 5
Additional Comments
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Should be Empty: