Patients Name: ______________________________________Date:____________________

Diagnoses __________________________________________________________________

Frequency & Duration of Treatment: _____________________________________________

Specific Goals: ______________________________________________________________

Precautions: ________________________________________________________________

________Evaluate & Treat

________Physical Therapy                          _________Treat only as specified

Modalities & Procedures                                           Joint Rehabilitation

________HotPacks/Cold Packs                                 ________Knee 
________Ultrasound                                                 ________Ankle 
________Electrical Stimulation                                ________Hip
________Ultrasound/E-Stim (combo)                       ________TMJ
________Vasopneumatic Compression/Cold            ________Shoulder
________Traction (Cervical/Pelvic)                         ________Elbow
________Paraffin                                                    ________Wrist
________Fluido Therapy                                         ________ Hand
________Iontophoresis/Phonophoresis
________Neuromuscular Re-Education
________Whirlpool

Manual Techniques                                                 Therapeutic Exercise

________Massage/Soft Tissue Mobilization             _________Home Program
________Joint Mobilization                                     _________Directed Clinic Program
________Manual Stretching                                   _________Gait Training
________Spray & Stretch
________Myofacial Release
________Muscle Energy--Strain Counter-Strain

Additional Comments____________________________________________________

I certify that the above treatment is medically necessary and is approved.
Physicians Signature____________________________________________________