Electrical Stimulation Modality Log

Clinical log for documenting electrical stimulation (e-stim) treatment details, electrode placement, parameters, treated area, contraindication screening, and patient response.

Session Details

• Date of Treatment
• Time of Treatment
• Treated Area
• Treatment Goal

Contraindication Screening

• Contraindication screening completed before application
• Does the patient have a pacemaker or implanted electronic device?
• Implanted Device Details
• No contraindications identified for this application
  Confirm that screening was completed and the application is appropriate per clinical protocol.

E-Stim Parameters

• Type of Electrical Stimulation
• Other Type
• Mode / Waveform
• Intensity
• Frequency (Hz)
• Pulse Width (µs)

Electrode Placement

• Electrode Placement Description
• Electrode Configuration
• Placement Photo
  Optional clinical reference image if permitted by policy.

Patient Response and Follow-Up

• Patient Tolerance
• Immediate Patient Response
• Response Details
• Follow-Up Action