SOR Work Conditioning Phase 2 — SOR Physical Therapy

Patient Identification & Session Timing

Used for CRM contact lookup and official session documentation.

All Fields Required

Patient First Name *

Patient Last Name *

Patient Email *

Patient Mobile Phone *

Session Date *

Start Time *

End Time *

Session Completion Progress0 of 43 Exercises Completed (0%)

Exercise	Prescribed	Actual Duration
Forward Treadmill	10 min	min
Bike	10 min	min
UBE	10 min	min

All prescribed at 2 × 10

Lift and Carry uses distance [ft], others use reps [#]

Exercise	Prescribed	Reps / Distance	Weight / Resistance
Lift and Carry Distance exercise (ft)	3 × 100 ft × 30 lbs	ft	lbs
Floor to Waist Lift	3 × 10 × 20 lbs	#	lbs
Reverse Cable Walkouts	3 × 10 × 40 lbs	#	lbs
Curl to Press	3 × 10 × 10 lbs	#	lbs
Woodchops	3 × 10 × 30 lbs	#	lbs

Page 2 Sheet

Includes conditional / excluded exercise field with note documentationPage 2 Sheet

Exercise	Prescribed	Actual Duration
Forward Treadmill	10 min	min
Bike	10 min	min
Optional Cool-Down Exercise Conditional / Excluded (Paper notation: 'Do not do')	—	min

All prescribed at 2 × 30 secPage 2 Sheet

Exercise	Prescribed	Duration Done
UT Stretch	2 × 30 sec	sec
Shoulder Horizontal Adduction Stretch	2 × 30 sec	sec
Pectoralis Stretch	2 × 30 sec	sec
Lat Dorsi Stretch	2 × 30 sec	sec
Hamstring Stretch	2 × 30 sec	sec
Hip Flexor Stretch	2 × 30 sec	sec
Quadriceps Stretch	2 × 30 sec	sec
Hip Adductor Stretch	2 × 30 sec	sec

Document patient response, pain ratings, modifications, and clinician sign-off.

Therapist Notes (progress, pain level, modifications, patient response)

Pain Level Today (0 = No Pain, 10 = Worst Possible Pain)

2 / 10

0 — No Pain3 — Mild5 — Moderate8 — Severe10 — Worst Pain

Therapist / Clinician Initials *

Required clinician electronic verification.

Patient Signature(Sign here with finger or stylus)

X Patient Signature LineTouch or stylus enabled

SOR PT Gary, IN • Work Conditioning Phase 2 • Secure CRM Sync