Extracorporeal Shockwave Therapy Report Patient Information:Patient Name(Required) First Last Patient Phone(Required)Patient Email(Required) Patient Social Security #(Required)Date of procedure(Required) MM slash DD slash YYYY DOB(Required) MM slash DD slash YYYY Referring physicians name(Required) First Last Office location and address where patient was treated(Required)Indications:Patient is a:(Required)Please enter a number from 1 to 125.Years oldGender(Required)MFRace(Required)WhiteBlack or African AmericanAmerican Indian or Alaska NativeAsianNative Hawaiian or Other Pacific IslanderHx(Required)Please enter a number from 1 to 120.Length of Disorder in monthsCondition(Required)(Diagnosis for area Tx this date)Patient has been previously treated with the following:(Required) Rest Ice NSAIDS Steroid Injections Physical Therapy Brace Surgery Pre-Treatment Imaging study(ies) performed:Circle either yes or noPlain X-ray(Required) Y N CT Scan(Required) Y N MRI Scan(Required) Y N Bone Scan(Required) Y N Procedure Report:This is Treatment Number:(Required)ofTotal Number of Treatments prescribed for this site/diagnosis:Position placed in: Supine Prone Sitting Lateral The patient was placed in the position (indicated above) and a pillow or wedge placed under the affected site to elbow for comfort and easy access. The variable energy Sonocur Basic Extracorporeal Shockwave Therapy System was used for treatment. The painful site or trigger point in the diagnosis area was identified by palpation. The treatment site was marked with a skin marker and ultrasound gel was placed over the site to be treated and the shock head was swung into place. The coupling bellow was placed over the identified painful site and the shock head adjusted in the x and y planes by movement of the suspension arm. Initial targeting shockwaves were applied at energy level one (1). Further fine adjustment was made in the x and y plains until the patient reported maximal stimulation of his/her painful area. The depth of shockwave penetration was then adjusted along the z axis by inflating or deflating the coupling bellow, again eliciting the maximal point of stimulation. After proper focusing, shock waves were delivered throughout the affected area. The shockwave focus was readjusted in the x, y, or z planes every 200-400 shocks to ascertain that the appropriate site was continually in focus.Additional Information:1.) At the time of this treatment, my pain level in the area to be treated is an (fill in field) with 10 being the greatest pain and 1 being the least pain.2.) At the time of this treatment, I am/I am not (check Y/N below) scheduled for surgery for the diagnosed problem that I’m being treated for. Yes No Treatment area 1 received (fill in field below) shocks(Required)At maximum energy level of (fill in below):(Required)Treatment area 2 received (fill in field below) shocks(Required)At maximum energy level of (fill in below):(Required)Treatment area 3 received (fill in field below) shocks(Required)At maximum energy level of (fill in below):(Required)Treatment area 4 received (fill in field below) shocks(Required)At maximum energy level of (fill in below):(Required)Total number of shocks delivered during ESWT treatment(Required)Other Comments:(Required)ESWT Physician Assistant Technician Signature(Required) First Last
