Extracorporeal Shockwave Therapy Report

Patient Information:

Patient Name(Required)
MM slash DD slash YYYY
MM slash DD slash YYYY
Referring physicians name(Required)


Please enter a number from 1 to 125.
Years old
Please enter a number from 1 to 120.
Length of Disorder in months
(Diagnosis for area Tx this date)
Patient has been previously treated with the following:(Required)

Pre-Treatment Imaging study(ies) performed:

Circle either yes or no
Plain X-ray(Required)
CT Scan(Required)
MRI Scan(Required)
Bone Scan(Required)

Procedure Report:

Position placed in:
The patient was placed in the position (indicated above) and a pillow or wedge placed under the affected site to elbow for comfort and easy access. The variable energy Sonocur Basic Extracorporeal Shockwave Therapy System was used for treatment. The painful site or trigger point in the diagnosis area was identified by palpation. The treatment site was marked with a skin marker and ultrasound gel was placed over the site to be treated and the shock head was swung into place. The coupling bellow was placed over the identified painful site and the shock head adjusted in the x and y planes by movement of the suspension arm. Initial targeting shockwaves were applied at energy level one (1). Further fine adjustment was made in the x and y plains until the patient reported maximal stimulation of his/her painful area. The depth of shockwave penetration was then adjusted along the z axis by inflating or deflating the coupling bellow, again eliciting the maximal point of stimulation. After proper focusing, shock waves were delivered throughout the affected area. The shockwave focus was readjusted in the x, y, or z planes every 200-400 shocks to ascertain that the appropriate site was continually in focus.

Additional Information:

2.) At the time of this treatment, I am/I am not (check Y/N below) scheduled for surgery for the diagnosed problem that I’m being treated for.
ESWT Physician Assistant Technician Signature(Required)