Work Conditioning — Phase 4

SOR Physical Therapy

SOR Physical Therapy · Gary, Indiana·HIPAA Clinical Exercise Sheet

Unified digital documentation tracking sheet covering Cardio Warm-up, Dynamic Mobility, Core Stabilization, Corrective Exercises, Functional Activities, Strength Training, Work Simulation, Cardio Cool-down, and Static Stretching.

Patient & Session Information

Used for CRM contact lookup, patient matching, 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 Progress:0 / 47 Exercises Completed 0%

CARDIO WARM-UP

EXERCISE	PRESCRIBED	ACTUAL DURATION
Forward Treadmill	10 min	min
Bike	10 min	min
UBE	10 min	min

DYNAMIC MOBILITY / STRETCHING

All prescribed at 2 × 10

EXERCISE	PRESCRIBED	SETS DONE	REPS DONE	COMPLETED
Arm Circles	2 × 10
Shoulder "W"	2 × 10
Standing Knee to Chest	2 × 10
Standing Quad Stretch	2 × 10
Standing Alt Toe Touch	2 × 10
Leg Swings — Forward/Backward	2 × 10
Squats	2 × 10
Posterior Lunges	2 × 10

CORE STABILIZATION

EXERCISE	PRESCRIBED	RESISTANCE / NOTES
Crunches	3 × 12	—
Bridges	3 × 12	—
Quadruped Alt Arm/Leg	3 × 12 Alt	Alt
Planks	3 × 30 sec	—
Pallof Press	3 × 10 × Green

DEFICIT / CORRECTIVE EXERCISES

EXERCISE	PRESCRIBED	WEIGHT USED (LBS)
Straight Leg Raises	3 × 10 × 3 lbs	lbs
S/L Hip Abduction	3 × 10 × 3 lbs	lbs
Prone Hip Extension	3 × 10 × 3 lbs	lbs

FUNCTIONAL ACTIVITIES

EXERCISE	PRESCRIBED	WEIGHT / RESISTANCE	NOTES
Lift and Carry	3 × 100 ft × 40 lbs	lbs	Both / Box
Cable Pull	3 × 10	lbs	Both / Single Arm Row
Reverse Cable Walkouts	3 × 10	lbs	—
Floor to Waist Lift	3 × 10	lbs	—
Reverse Woodchops	3 × 10	lbs	—

STRENGTH TRAINING

Shoulder & Upper Body FocusPAGE 2 SHEET

EXERCISE	PRESCRIBED	WEIGHT / RESISTANCE	NOTES
Chest Press	3 × 12 × 10 lbs	lbs	DB
Incline Press	3 × 12 × 10 lbs	lbs	DB / 45° bench
Punches	3 × 12 × 10 lbs	lbs	Single Arm / DB
Shoulder Press	3 × 12 × 20 lbs	lbs	DB
Tricep Extension (Band)	3 × 12 × Green Band		Band
Tricep Extension (Overhead)	3 × 15 × 10 lbs	lbs	Overhead
Lateral Raises	3 × 12 × 10 lbs	lbs	DB
Front Raises	3 × 12 × 5 lbs	lbs	Alt / DB
"I", "Y", "T" Shoulder	3 × 12 × Red Bands		Bands
Shoulder Extension	3 × 12 × Red Bands		Bands

WORK SIMULATION

PAGE 2 SHEET

EXERCISE	PRESCRIBED	SETS DONE	REPS / DURATION DONE	WEIGHT / RESISTANCE	NOTES	COMPLETED
Med Ball Squat to Over Shoulder	2 × 2 min × 10 lbs			lbs	Med Ball
Trunk Rotation	3 × 10 × 10 lbs			lbs	—

CARDIO COOL-DOWN

PAGE 2 SHEET

EXERCISE	PRESCRIBED	ACTUAL DURATION
Forward Treadmill	10 min	min
Bike	10 min	min
UBE	10 min	min

STATIC STRETCHING / MOBILITY

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

Session Notes & Clinical Sign-Off

Final clinical observation, patient response rating, and electronic signatures.

Therapist Notes

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)

✕ PATIENT SIGNATURE LINETouch or stylus enabled