ARPWAVE TREATMENT REPORT
 
Enter Treatment Session Number:
Treatment Session 1
Treatment Session 2
Treatment Session 3
Treatment Session 4
Treatment Session 5
Treatment Session 6
Treatment Session 7
Treatment Session 8
Treatment Session 9
Treatment Session 10
OR
Treatment Session 11
Treatment Session 12
Treatment Session 13
Treatment Session 14
Treatment Session 15
Treatment Session 16
Treatment Session 17
Treatment Session 18
Treatment Session 19
Treatment Session 20
Type of Session
Treatment Recovery Personal Use
ARPwave Unit Serial Number:
Patient Name:
Time on unit (Start):
City:
State:
Date (mm-dd-yyyy):
ARP Staff Therapist Name:
ARP Staff Therapist Email:
Clinic Name:
Doctors Name:
TREATMENT SESSION DATA:
Condition Being Treated:
After Treatment How Long Did It Take For Pain To Come Back:
After Treatment How Long Did It Take For Other Symptoms To Come Back:
What Level Did It Come Back To:
What Did You Do After Treatment:
Pain Level Out of Bed:
1 - Lowest 2 3 4 5 6 7 8 9 10 - Highest
Pain Level Walking:
1 - Lowest 2 3 4 5 6 7 8 9 10 - Highest
Present Pain Level:
1 - Lowest 2 3 4 5 6 7 8 9 10 - Highest
Did they dream last night:
Yes No
Did they follow eating plan:
Yes No
Sore:
Yes No
In Balance:
Yes No
Notes:
TREATMENTS 1-20
CABLE 1-BLACK:
CABLE 1-RED:
CABLE 2-BLACK:
CABLE 2-RED:
Approved Strength Movement:
Main Pulse:
Duty (Example: 20-20, 1 on, 0 off - NO back slashes or forward slashes):
Normal Polarity Max:
Reverse Polarity Max:
Time on unit (End):
Total time used:
Pain Level After Treatment:
1 - Lowest 2 3 4 5 6 7 8 9 10 - Highest
Notes (Cannot contain backslashes or forwardslashes):
Force Test:
10 at Half Speed:
Full Speed:
IF PAYING BY SESSIION:
Credit Card:
Visa Mastercard American Express
Credit Card #:
Amount:
Exp Date (mm-yy):
Sec #:
Name Shown On Card:
Billing Address:
OR...
Check Number:
Account Number:
ABA Routing Number:
Amount:
Notes:
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