Soap Notes
Please fill out the following form to provide soap notes for an acupuncture session.
Patient Information
Full Name
First Name
Last Name
Todays Date
*
-
Month
-
Day
Year
Date
Insurance
Please Select
Regency
United Health Care
TriWest
Aetna
Kaiser
Providence
NONE
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Chief Complaints
Medical History/Txt Diagnosis
Treatment Requested / CPT Code
97124 - Massage Therapy
97139 - Cupping
97010 - Hot/Cold Packs
Other
Treatment Requested
Medical Massage
Manual Lymphatic Drainage
Cupping/Decompression Therapy
Hot Stones
Cold Stones
Deep Tissue
Wellness Massage
Swedish Massage
Session Length
30 Minutes
45 minutes
60 minutes
75 minutes
90 minutes
120 minutes
Units
1 unit - 15 minutes
4 units - 60 minutes
2 units - 30 minutes
5 units - 75 minutes
3 units - 45 minutes
6 units - 90 minutes
Pain Assessment (Beginning)
*
1
2
3
4
5
6
7
8
9
10
Client Description of Symptoms
Subjective
Objective
Severity
Mild
Severe
Moderate
With in Normal Range
Other
Observed Tissue
HT
ADH
Fiboris
Muscle Tension
Trigger Points
Muscle Spasms
Other
Modalities Techniques
Swedish
Medical Massage
Manual Lymphatic Drainage
Hypervolt
Cupping/Decompression Therapy
CFF
Pin and Stretch
MFR
Muscle Stripping
Hot Stones
Cold Stones
Deep Tissue
PROM/AROM
Red Light Therapy
Trigger Point Therapy
Other
Assessment
Pain Assessment (POST)
*
1
2
3
4
5
6
7
8
9
10
Plan
Additional Notes
Submit
Should be Empty: