Patient Name: ____________________________________

Admitting Diagnosis: 1._____________________________

Somatic Dysfunction Found:
____yes
____no

Somatic Dysfunction Diagnosed at (check):

A.____ Head (739.0)        F.____ Pelvis (739.5)
B.____ Cervical (739.1)    G.____ L. Extremity (739.6)
C.____ Thoracic (739.2)  H.____ U. Extremity (739.7)
D.____ Lumbar (739.3)    I. ____ Ribs (739.8)
E.____ Sacrum (739.4)    J. ____ Abdomen (739.9)

Osteopathic Manipulative Treatment (OMT) Techniques Used:

1. General Mobilization (93.61)
2. High Velocity Low Amplitude (93.62)
3. Articulatory–Rib Raising (93.63)
4. Muscle Energy–Isometric (93.64)
5. Indirect (93.65)
6. Lymphatic Pump (93.66)
7. Fascial Release (93.67)

Reason If Not Treated:_______________________________________________________

_______________________________________
Date———–Signature of Physician (Attending)

©1992 Richard A. Feely, D.O. All rights reserved.