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

Work Conditioning

Phase 5

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

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 Progress: 0 / 39 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	Reps / Time Done	Resistance / Notes
Supine Reverse Marches	3 × 12 × 2 lbs		lbs
Bridges	3 × 12 × Blue
Planks	3 × 30 sec	sec	—
Ball Toss	3 × 12 × Blue
Pallof Press	3 × 12 × Red Bands

DEFICIT / CORRECTIVE EXERCISES (Wrist)

All prescribed at 3 × 10 × 5 lbs

Exercise	Prescribed	Weight Used (lbs)
Wrist Extension	3 × 10 × 5 lbs	lbs
Wrist Flexion	3 × 10 × 5 lbs	lbs
Wrist Radial Deviation	3 × 10 × 5 lbs	lbs
Wrist Ulnar Deviation	3 × 10 × 5 lbs	lbs
Supination / Pronation	3 × 10 × 5 lbs	lbs

FUNCTIONAL ACTIVITIES

Exercise	Prescribed	Reps / Distance Done	Weight / Resistance
Lift and Carry	10 × 50 ft × 5 lbs	ft	lbs
Trunk Rotation	3 × 10
Curl to Press	3 × 10 × 15 lbs		lbs

STRENGTH TRAINING

PAGE 2 SHEET

Exercise	Prescribed	Reps / Distance / Time Done	Weight / Resistance
Crossover Step Ups	3 × 10 × 15 lbs		lbs
Step Ups	3 × 15 × 15 lbs		lbs
Posterior Lunges	3 × 10		—
Low Rows	3 × 10 × Red Band
Lift to Press	3 × 10 × 20 lbs		lbs
Punches	3 × 10 × Green Band
Single Leg Balance	3 × 45 sec	sec	—
Lateral Walking	3 × 50 ft × Blue Bands	ft
Fwd/Bwd Combo Walking	3 × 50 ft × Blue	ft
Wall Dribbles	3 × 1 min × Red	min
Squats	3 × 15 × 15 lbs		lbs

WORK SIMULATION

PAGE 2 SHEET

Exercise	Prescribed	Sets Done	Reps / Duration Done	Weight / Resistance	Notes	Completed
Tray Carry	5 × 100 ft × 20 lbs		ft	lbs
Supination / Pronation	3 × 10			—

CARDIO COOL-DOWN

PAGE 2 SHEET

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

Clinical Session Notes & Sign-Off

Therapist Notes

Pain Level Today (0 = No Pain, 10 = Worst Possible Pain)2 / 10

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

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SOR PT Gary, IN · Work Conditioning Phase 5 · Secure CRM Sync