SOAP Note
_________________________________________ _________________________________________
Client Name Session Type
_________________________________________ _________________________________________
Date of Service Duration
SUBJECTIVE
Pain
Hypertonicity
Tender point
Trigger point
Adhesion
Swelling
Elevation
Rotation
Pain intensity (circle):
1 2 3 4 5 6 7 8 9 10
Pain location: _________________________________________________________________________________________________
Pain description: ______________________________________________________________________________________________
Pain onset (when, cause): _____________________________________________________________________________________
What makes symptoms worse? _______________________________________________________________________________
What relieves symptoms? ____________________________________________________________________________________
Other subjective information: ________________________________________________________________________________
_______________________________________________________________________________________________________________
OBJECTIVE
Range of Motion (e.g. restrictions, measurements): Other Objective Notes:
________________________________________________________
________________________________________________________
Visual Observations (e.g. posture, movement):
________________________________________________________
________________________________________________________
Palpation (e.g. tone, texture, tenderness, temperature):
________________________________________________________
________________________________________________________
TREATMENTS
Areas treated today:
Neck Chest Swedish Hot Stone Stretching Aromatherapy
Deep tissue Shiatsu Hydrotherapy Chair Massage
Face / Jaw Abdominals
Myofascial Trigger Point Reflexology Lymphatic
Back Pelvis / Hips
Sports Thai Massage Energy work Medical Massage
Shoulders Legs
Arms Feet Other Treatments: __________________________________________________
______________________________________________________________________
ASSESSMENT
Response to today's treatment:
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
PLAN
Treatment Plan for next session (e.g. when, duration, frequency, modalities):
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Client education / self-care recommendations: Stretching: __________________________________________
____________________________________________________ Exercise: ____________________________________________
____________________________________________________ Cold / Heat: _________________________________________
Other: _______________________________________________
_________________________________________ ________/________/________
Therapist Signature Date
