Work Conditioning

PHASE 1

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, and Hand/Wrist Strengthening.

Patient Identification & Session Timing

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 Progress0 of 38 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 Wide	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	Sets Done	Reps / Time Done	Resistance / Notes	Completed
Crunches	3 × 12
Bridges	3 × 12
Quadruped Alt Arm/Leg	3 × 12 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
Lift and Carry	3 × 100 ft × 40 lbs	lbs
Cable Pull	3 × 10 (Green band)
Reverse Cable Walkouts	3 × 10 (Green band)
Floor to Waist Lift	3 × 10	lbs
Reverse Woodchops	3 × 10 (Green, cable from bottom)

Supplemental Core / Lower Extremity

Page 2 Sheet

Exercise	Prescribed	Resistance / Band
Supine Marches	3 × 10 × 3 lbs	lbs
Crunches	3 × 10
Bridges	3 × 10 × Blue
Clams	3 × 10 × Blue
Side Planks	3 × 30 sec
Pallof Press	3 × 10 × Red Bands

Hand / Wrist Strengthening (Theraputty, FlexBar & Gripper)

Page 2 Sheet

Exercise	Prescribed	Sets Done	Reps / Duration
Putty Weight Bearing	3 × Red		—
Wrist Roller	3 sets		—
FlexBar — Radial/Ulnar Deviation	2 × Green
FlexBar — Wrist Flex/Extension	2 × Green
FlexBar — Pronation	2 × Green
FlexBar — Supination	2 × Green
Gripper (Calibrated)	5 min / 10 sec hold	—
Gripper (Red)	5 min / 10 sec hold per squeeze	—

Session Notes & Sign-Off

Therapist Notes

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

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

Therapist / Clinician Initials *

Required clinician electronic verification.

Patient Signature *

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SOR PT Gary, IN · Work Conditioning Phase 1 · Secure CRM Sync