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Knee Level 1 Flow Sheet
Program Treatment Flow Sheet — Knee Level 1
SOR Physical Therapy
Patient & Session Information
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| Treatment | Protocol Ref | Visit 1 | Visit 2 | Visit 3 | Visit 4 | Visit 5 | Visit 6 | Visit 7 | Visit 8 | |
|---|---|---|---|---|---|---|---|---|---|---|
| Knee PROM | ||||||||||
| Quad Sets | ||||||||||
| SAQ | ||||||||||
| Heel Slides | ||||||||||
| Straight Leg Rz | ||||||||||
| Adduction Sq | ||||||||||
| Abduction Band | ||||||||||
| Knee Ext | ||||||||||
| Gastroc Stretch | ||||||||||
| Lunges | ||||||||||
| Mini Squats | ||||||||||
| Step Up Forward | ||||||||||
| Step Up Lateral | ||||||||||
| Squat | ||||||||||
| Tandum Bal | ||||||||||
| Single Leg Bal | ||||||||||
| Wobble Board | ||||||||||
| Lateral Walks | ||||||||||
| Band Walkout | ||||||||||
| Band Pullout | ||||||||||
| Knee Ext Mach | ||||||||||
| Hamstring Mach | ||||||||||
| Bike | ||||||||||
Columns: 8 Visits•Rows: 23 named + 1 divider + 3 custom
© 2026 Sport Orthopedic Rehabilitative Service, INC. All Rights Reserved.
Sport Orthopedic Rehabilitative Service, INC.
Program Treatment Flow Sheet — Knee Level 1
Patient Name: ________________________
Diagnosis: ________________________
Printed: 10/20/2026
| Treatment | Protocol Ref | Visit 1 MM/DD/YYYY | Visit 2 MM/DD/YYYY | Visit 3 MM/DD/YYYY | Visit 4 MM/DD/YYYY | Visit 5 MM/DD/YYYY | Visit 6 MM/DD/YYYY | Visit 7 MM/DD/YYYY | Visit 8 MM/DD/YYYY |
|---|---|---|---|---|---|---|---|---|---|
| Knee PROM | 5 min | ||||||||
| Quad Sets | 2x20 | ||||||||
| SAQ | 3x10 | ||||||||
| Heel Slides | 1x30 | ||||||||
| Straight Leg Rz | 3x10 | ||||||||
| Adduction Sq | 1x20 | ||||||||
| Abduction Band | 1x20 | ||||||||
| Knee Ext | 3x10 | ||||||||
| Gastroc Stretch | 1x30 | ||||||||
| Lunges | 1x20 | ||||||||
| Mini Squats | 1x20 | ||||||||
| Step Up Forward | 2x20 | ||||||||
| Step Up Lateral | 2x20 | ||||||||
| Squat | 2x20 | ||||||||
| Tandum Bal | 3x30 sec | ||||||||
| Single Leg Bal | 3x30 sec | ||||||||
| Wobble Board | 2x2 min | ||||||||
| Lateral Walks | 2x 100ft | ||||||||
| Band Walkout | 2x10 | ||||||||
| Band Pullout | 2x10 | ||||||||
| Knee Ext Mach | 3x10 | ||||||||
| Hamstring Mach | 3x10 | ||||||||
| Bike | 10 min | ||||||||
| Custom Row 1 | |||||||||
| Custom Row 2 | |||||||||
| Custom Row 3 | |||||||||
Sport Orthopedic Rehabilitative Service, INC. | Questions? Call us at (219) 981-8109 | This form contains Protected Health Information (PHI) and is handled per HIPAA protocols.