Patient Name: ____________________________________

Admitting Diagnosis: 1._____________________________

Somatic Dysfunction Found:
____yes
____no

Somatic Dysfuunction 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)

Date	Treated Regions	Technique Used	Comments	Treated By
_______	________________	________________	________________	______________
_______	________________	________________	________________	______________
_______	________________	________________	________________	______________
_______	________________	________________	________________	______________
_______	________________	________________	________________	______________
_______	________________	________________	________________	______________

Reason If Not Treated:_________________________________________________________

_______________________________________
Date-----------Signature of Physician (Attending)