Sport Orthopedic Rehabilitative Service, INC.

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Program Treatment Flow Sheet — Cervical

Patient Information & Clinical Order

Patient Name *

Diagnosis *

Treatment Rows: 23 standard clinical exercises + 3 customizable rows (26 total). All repeat rows and original abbreviations preserved.

Columns: 8 VisitsLeft column locked horizontally

TreatmentCervical	Visit 1 Visit 1 Date (MM/DD/YYYY)	Visit 2 Visit 2 Date (MM/DD/YYYY)	Visit 3 Visit 3 Date (MM/DD/YYYY)	Visit 4 Visit 4 Date (MM/DD/YYYY)	Visit 5 Visit 5 Date (MM/DD/YYYY)	Visit 6 Visit 6 Date (MM/DD/YYYY)	Visit 7 Visit 7 Date (MM/DD/YYYY)	Visit 8 Visit 8 Date (MM/DD/YYYY)
1.STMB	STMB — Visit 1, Col 1	STMB — Visit 2, Col 2	STMB — Visit 3, Col 3	STMB — Visit 4, Col 4	STMB — Visit 5, Col 5	STMB — Visit 6, Col 6	STMB — Visit 7, Col 7	STMB — Visit 8, Col 8
2.Cervical AROM	Cervical AROM — Visit 1, Col 1	Cervical AROM — Visit 2, Col 2	Cervical AROM — Visit 3, Col 3	Cervical AROM — Visit 4, Col 4	Cervical AROM — Visit 5, Col 5	Cervical AROM — Visit 6, Col 6	Cervical AROM — Visit 7, Col 7	Cervical AROM — Visit 8, Col 8
3.Cervical Ext	Cervical Ext — Visit 1, Col 1	Cervical Ext — Visit 2, Col 2	Cervical Ext — Visit 3, Col 3	Cervical Ext — Visit 4, Col 4	Cervical Ext — Visit 5, Col 5	Cervical Ext — Visit 6, Col 6	Cervical Ext — Visit 7, Col 7	Cervical Ext — Visit 8, Col 8
4.Cervical Flexion	Cervical Flexion — Visit 1, Col 1	Cervical Flexion — Visit 2, Col 2	Cervical Flexion — Visit 3, Col 3	Cervical Flexion — Visit 4, Col 4	Cervical Flexion — Visit 5, Col 5	Cervical Flexion — Visit 6, Col 6	Cervical Flexion — Visit 7, Col 7	Cervical Flexion — Visit 8, Col 8
5.Cer. Side Bending	Cer. Side Bending — Visit 1, Col 1	Cer. Side Bending — Visit 2, Col 2	Cer. Side Bending — Visit 3, Col 3	Cer. Side Bending — Visit 4, Col 4	Cer. Side Bending — Visit 5, Col 5	Cer. Side Bending — Visit 6, Col 6	Cer. Side Bending — Visit 7, Col 7	Cer. Side Bending — Visit 8, Col 8
6.Cervical Rotation	Cervical Rotation — Visit 1, Col 1	Cervical Rotation — Visit 2, Col 2	Cervical Rotation — Visit 3, Col 3	Cervical Rotation — Visit 4, Col 4	Cervical Rotation — Visit 5, Col 5	Cervical Rotation — Visit 6, Col 6	Cervical Rotation — Visit 7, Col 7	Cervical Rotation — Visit 8, Col 8
7.Cerv. Iso. 4 Way	Cerv. Iso. 4 Way — Visit 1, Col 1	Cerv. Iso. 4 Way — Visit 2, Col 2	Cerv. Iso. 4 Way — Visit 3, Col 3	Cerv. Iso. 4 Way — Visit 4, Col 4	Cerv. Iso. 4 Way — Visit 5, Col 5	Cerv. Iso. 4 Way — Visit 6, Col 6	Cerv. Iso. 4 Way — Visit 7, Col 7	Cerv. Iso. 4 Way — Visit 8, Col 8
8.Wall Angels	Wall Angels — Visit 1, Col 1	Wall Angels — Visit 2, Col 2	Wall Angels — Visit 3, Col 3	Wall Angels — Visit 4, Col 4	Wall Angels — Visit 5, Col 5	Wall Angels — Visit 6, Col 6	Wall Angels — Visit 7, Col 7	Wall Angels — Visit 8, Col 8
9.Wall Push Off	Wall Push Off — Visit 1, Col 1	Wall Push Off — Visit 2, Col 2	Wall Push Off — Visit 3, Col 3	Wall Push Off — Visit 4, Col 4	Wall Push Off — Visit 5, Col 5	Wall Push Off — Visit 6, Col 6	Wall Push Off — Visit 7, Col 7	Wall Push Off — Visit 8, Col 8
10.Seat Thor. Ext	Seat Thor. Ext — Visit 1, Col 1	Seat Thor. Ext — Visit 2, Col 2	Seat Thor. Ext — Visit 3, Col 3	Seat Thor. Ext — Visit 4, Col 4	Seat Thor. Ext — Visit 5, Col 5	Seat Thor. Ext — Visit 6, Col 6	Seat Thor. Ext — Visit 7, Col 7	Seat Thor. Ext — Visit 8, Col 8
11.Seat Thor. Rot	Seat Thor. Rot — Visit 1, Col 1	Seat Thor. Rot — Visit 2, Col 2	Seat Thor. Rot — Visit 3, Col 3	Seat Thor. Rot — Visit 4, Col 4	Seat Thor. Rot — Visit 5, Col 5	Seat Thor. Rot — Visit 6, Col 6	Seat Thor. Rot — Visit 7, Col 7	Seat Thor. Rot — Visit 8, Col 8
12.I-T-Y	I-T-Y — Visit 1, Col 1	I-T-Y — Visit 2, Col 2	I-T-Y — Visit 3, Col 3	I-T-Y — Visit 4, Col 4	I-T-Y — Visit 5, Col 5	I-T-Y — Visit 6, Col 6	I-T-Y — Visit 7, Col 7	I-T-Y — Visit 8, Col 8
13.Lat. Pull Down	Lat. Pull Down — Visit 1, Col 1	Lat. Pull Down — Visit 2, Col 2	Lat. Pull Down — Visit 3, Col 3	Lat. Pull Down — Visit 4, Col 4	Lat. Pull Down — Visit 5, Col 5	Lat. Pull Down — Visit 6, Col 6	Lat. Pull Down — Visit 7, Col 7	Lat. Pull Down — Visit 8, Col 8
14.Low Rows	Low Rows — Visit 1, Col 1	Low Rows — Visit 2, Col 2	Low Rows — Visit 3, Col 3	Low Rows — Visit 4, Col 4	Low Rows — Visit 5, Col 5	Low Rows — Visit 6, Col 6	Low Rows — Visit 7, Col 7	Low Rows — Visit 8, Col 8
15.High Rows	High Rows — Visit 1, Col 1	High Rows — Visit 2, Col 2	High Rows — Visit 3, Col 3	High Rows — Visit 4, Col 4	High Rows — Visit 5, Col 5	High Rows — Visit 6, Col 6	High Rows — Visit 7, Col 7	High Rows — Visit 8, Col 8
16.Form Rollout For	Form Rollout For — Visit 1, Col 1	Form Rollout For — Visit 2, Col 2	Form Rollout For — Visit 3, Col 3	Form Rollout For — Visit 4, Col 4	Form Rollout For — Visit 5, Col 5	Form Rollout For — Visit 6, Col 6	Form Rollout For — Visit 7, Col 7	Form Rollout For — Visit 8, Col 8
17.Form Rollout Lat	Form Rollout Lat — Visit 1, Col 1	Form Rollout Lat — Visit 2, Col 2	Form Rollout Lat — Visit 3, Col 3	Form Rollout Lat — Visit 4, Col 4	Form Rollout Lat — Visit 5, Col 5	Form Rollout Lat — Visit 6, Col 6	Form Rollout Lat — Visit 7, Col 7	Form Rollout Lat — Visit 8, Col 8
18.Ball Upp Wall	Ball Upp Wall — Visit 1, Col 1	Ball Upp Wall — Visit 2, Col 2	Ball Upp Wall — Visit 3, Col 3	Ball Upp Wall — Visit 4, Col 4	Ball Upp Wall — Visit 5, Col 5	Ball Upp Wall — Visit 6, Col 6	Ball Upp Wall — Visit 7, Col 7	Ball Upp Wall — Visit 8, Col 8
19.Wall Push Off	Wall Push Off — Visit 1, Col 1	Wall Push Off — Visit 2, Col 2	Wall Push Off — Visit 3, Col 3	Wall Push Off — Visit 4, Col 4	Wall Push Off — Visit 5, Col 5	Wall Push Off — Visit 6, Col 6	Wall Push Off — Visit 7, Col 7	Wall Push Off — Visit 8, Col 8
20.Wall Angel	Wall Angel — Visit 1, Col 1	Wall Angel — Visit 2, Col 2	Wall Angel — Visit 3, Col 3	Wall Angel — Visit 4, Col 4	Wall Angel — Visit 5, Col 5	Wall Angel — Visit 6, Col 6	Wall Angel — Visit 7, Col 7	Wall Angel — Visit 8, Col 8
21.Wall Claps	Wall Claps — Visit 1, Col 1	Wall Claps — Visit 2, Col 2	Wall Claps — Visit 3, Col 3	Wall Claps — Visit 4, Col 4	Wall Claps — Visit 5, Col 5	Wall Claps — Visit 6, Col 6	Wall Claps — Visit 7, Col 7	Wall Claps — Visit 8, Col 8
22.Wall Swims	Wall Swims — Visit 1, Col 1	Wall Swims — Visit 2, Col 2	Wall Swims — Visit 3, Col 3	Wall Swims — Visit 4, Col 4	Wall Swims — Visit 5, Col 5	Wall Swims — Visit 6, Col 6	Wall Swims — Visit 7, Col 7	Wall Swims — Visit 8, Col 8
23.UBE	UBE — Visit 1, Col 1	UBE — Visit 2, Col 2	UBE — Visit 3, Col 3	UBE — Visit 4, Col 4	UBE — Visit 5, Col 5	UBE — Visit 6, Col 6	UBE — Visit 7, Col 7	UBE — Visit 8, Col 8
24. Edit Custom Row 1	Custom Row 1 — Visit 1, Col 1	Custom Row 1 — Visit 2, Col 2	Custom Row 1 — Visit 3, Col 3	Custom Row 1 — Visit 4, Col 4	Custom Row 1 — Visit 5, Col 5	Custom Row 1 — Visit 6, Col 6	Custom Row 1 — Visit 7, Col 7	Custom Row 1 — Visit 8, Col 8
25. Edit Custom Row 2	Custom Row 2 — Visit 1, Col 1	Custom Row 2 — Visit 2, Col 2	Custom Row 2 — Visit 3, Col 3	Custom Row 2 — Visit 4, Col 4	Custom Row 2 — Visit 5, Col 5	Custom Row 2 — Visit 6, Col 6	Custom Row 2 — Visit 7, Col 7	Custom Row 2 — Visit 8, Col 8
26. Edit Custom Row 3	Custom Row 3 — Visit 1, Col 1	Custom Row 3 — Visit 2, Col 2	Custom Row 3 — Visit 3, Col 3	Custom Row 3 — Visit 4, Col 4	Custom Row 3 — Visit 5, Col 5	Custom Row 3 — Visit 6, Col 6	Custom Row 3 — Visit 7, Col 7	Custom Row 3 — Visit 8, Col 8

Appends a blank visit column to the right. Existing clinical data is preserved.