SOAP Notes Form
Therapist/Clinic Name: LaToya Cox-Thomas, LMT/ Serenity Services LLC
Contact Information: (334)524-7333
Client Name:
DOB:
Ins. ID#:
Subjective- Client symptoms and information given by client and referring health care provider:
Objective- Clinical observation derived from interviews, palpation, visual exam, and posture assessment:
Assessment- Treatment used and client response to the treatment:
Plan of treatment- Treatment options, recommendations, and self-care plan
Date:
Duration:
Symptom 1 Location
Head-Right Side
Head-Left Side
Head-Front
Head-Back
Neck-Right Side
Neck-Left Side
Neck-Front
Neck-Back
Shoulders-Right Side
Shoulders-Left Side
Chest
Upper Back
Upper Arm-Right Side
Upper Arm-Left Side
Lower Arm-Right Side
Lower Arm-Left Side
Hand-Right
Hand-Left
Mid Back
Mid Front
Lower Back
Abdomen
Right Side
Left Side
Pelvic Area
Buttocks
Upper Thigh-Right Side
Upper Thigh-Left Side
Back Upper Thigh-Right Side
Back Upper Thigh-Left Side
Knee-Right
Knee-Left
Back of Knee-Right
Back of Knee-Left
Shin-Right
Shin-Left
Calf-Right
Calf-Left
Foot-Right
Foot-Left
Symptom 1 Intensity
Symptom 1 Duration
Symptom 1 Frequency
Symptom 1 Onset
Sympton 1:
Adhesion
Rotation
Pain
Tender points
Hypertonicity
Spasm
Inflammation
Trigger point
Elevation
Sympton 1 notes: