Physical Therapy Prescription
Your caregiver wants you to have physical therapy. Please take this instruction to the physical therapist recommended by your caregiver. Your prescription is:
___ Evaluate and treat using standard techniques.
___ Evaluate and contact physician before starting treatment.
___ Heat therapy: ( ) Ultrasound ( ) Hot Packs ( ) Paraffin.
___ Electrotherapy: ( ) TENS ( ) Electrical Stimulation.
___ Therapeutic Exercise: ( ) Back ( ) Neck ( ) Gait ( ) Home program.
___ Traction: ( ) Pelvic ( ) Cervical.
___ Posture and body mechanics education.
Treatment Goal: ___________________________________________________________
___ Times per week for ___ weeks. Please send progress note to caregiver at the completion of therapy. Call caregiver if patient's condition becomes worse.