ESWT Intake Extracorporeal Shockwave Therapy ReportName:(Required) First Last SS#:DOB:(Required) MM slash DD slash YYYY Referring physician's name:Office location and address where patient was treated:1805 E Dyer Rd, #110 Santa Ana, CA 927051225 W. 190th St. #425 Gardena, CA 90248UntitledPatient is a _____ year old (Gender)(Race)with a (Length of Disorder) Hx of (Diagnosis for area Tx this date) Patient has been previously treated with the following:(Required) Select All Rest Ice NSAIDS Steroid Injection(s) Physical Therapy Brace Surgery Pre-Treatment Imagine study(ies) performed: Plain x-ray CT Scan MRI Bone Scan Treatment numberNumberCurrentNumberTotalThe patient was placed in the _____ position and a pillow or wedge placed under the affected site to elbow for comfort and easy access.supinepronesittinglateralThe 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 re-adjusted in the x, y, or z planes every 200-400 shocks to ascertain that the appropriate site was continually in focus.Additional Information1) At the time of this treatment, my pain level in the area to be treated is a _____with 10 being the greatest pain and 1 being the least pain.(Required)Please enter a number from 1 to 10.2) At the time of this treatment, I __________ for the diagnosed problem that I’m being treated for.am scheduled for surgeryam not scheduled for surgeryPatient SignaturePatient NamePrintTreatment area 1 received __________shocksPlease enter a number from 2000 to 99999.at maximum energy level__________123Treatment area 2 received __________shocksPlease enter a number from 2000 to 99999.at maximum energy level__________123Treatment area 3 received __________shocksPlease enter a number from 2000 to 99999.at maximum energy level__________123Treatment area 4 received __________shocksPlease enter a number from 2000 to 99999.at maximum energy level__________123Total number of shocks delivered during ESWT treatment.Please enter a number from 2000 to 99999.Note: Most procedures will have only one treatment site with the exception of Rotator Cuff Syndrome which may have three. Other Comments:At the conclusion of the treatment, the shock head was removed and the gel wiped away.
