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.

___ Hydrotherapy.

___ Cryotherapy.

___ Therapeutic Exercise: ( ) Back ( ) Neck ( ) Gait ( ) Home program.

___ Massage.

___ 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.