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Medical Record Number

Name
Age
Occupation
Hobbies

P R O G R E S S R EP O R T

PAIN SCALE Range of Motion (ROM)


Visual Analogue Score (VAS) 12
12 10
10 8
8
6
6
4 4
2 2
0 0
Sesi 1 Sesi 2 Sesi 3 Sesi 4 Sesi 5 Sesi 6 Sesi 1 Sesi 2 Sesi 3 Sesi 4 Sesi 5 Sesi 6

VAS ROM

NOTES
Examination

Therapy

Jakarta, ____________________

___________________________

PT. WELSPRO INSPIRASI UTAMA


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