Therapy Treatment Plan

1. P
Doctor: AlishaSenechal,DC,CACCP Date:______________
PatientName:__________________________________________________________
TREATMENT IS MEDICALLY NECESSARY
Please review and signthe below stated Therapy Treatment Plan forour mutual patient. Approval by the patients
Primary Care Physicianisrequiredby the patients’Medical Insuranceto show cohesivenessin care amongtreating
doctors.
Modalities/Procedures Conditionis relatedto:
97012______ Traction Therapy
97014______ Muscle StimulationTherapy
97124______ Massage Therapy _____Auto Accident Date of Injury________
97140______ Manual TherapyTechniques _____Work Injury
97010______ Hot or ColdPacks _____Illness
______ Therapistsdiscretion _____Other _____________________________
DiagnosisCodes
M54.2 ____ Cervicalgia
M54.6 ____ Thoracalgia
M54.5 ____ Lumbago
M54.41 ____ Lumbagow/ Rt. Sciatica
M54.42 ____ Lumbagow/ Lt. Sciatica
Other:__________________________
Duration and FrequencyofTreatment:
______times per weekfor______ weeks OR ______treatments OR ___________________________________
SessionLength: ____30 minutes ____60 minutes
Treatment Goals: Other Instructions:
____Decrease Pain Provide Yes No
____Decrease Inflammation Self-Care Education __ __
____Decrease Muscle Tension/Spasms Exercise Education __ __
____Increase Mobility/Rangeof Motion ErgonomicEducation __ __
____Decrease Stiffness
____Reduce Edema
____Other_______________________
Additional Notes: ___________________________________________________________________________________
AlishaSenechal,DC,CACCP:________________________________ Date: __________________________________
Nikki Glinski,NCMT:______________________________________ Date: __________________________________
Primary Care Physician: ____________________________________ Date: __________________________________
Senechal FamilyChiropractic
30802 LyonCenterDr. E
NewHudson,MI 48165
(248)-486-4000
X Pain
O Muscle Spasm
/ Sprain/Strain
T Tightness
Therapy Treatment Plan