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PRESCRIPTION FORM

PATIENT INFORMATION

First Name *

Last Name *

Date of Birth/D.O.B *

Phone *

Email *

Diagnosis

Precautions

Frequency

Therapy

PT - Physical Therapy

OT - Occupational Therapy

SP - Speech Therapy

Frequency/Duration

Times/Week
# of Weeks

EVALUATION

Evaluate and Treat

Evaluate for skilled therapy services and treat as necessary

TREATMENT PROCEDURES

TxProcedures

Functional Task Training

Therapeutic Exercise

Passive

Active

Active Resistance

Resistance

Muscle Stretching

Gait Training

Neuromuscular Re-Education

Vestibular and Balance Rehabilitation

Mammal Lymph Drainage

Tx Procedures 2

Massage/Soft Tissue Mobilization

Myofacial Release

Manual Traction

Joint Mobilization

Hot/Cold Packs

Ultrasound

Electrical Stimulation

PROTOCOLS

Protocols

Check here if supplying your own

ACL Protocol

Rotator Cuff Repair Protocol

Total Hip Protocol

Protocols 2

Total Knee Protocol

Total Shoulder Protocol

McKenzie Extension

Weight Bearing Restrictions

Comments/Concerns

Physician Signature *

Physician Name *

Date *

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(561) 964-2526

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rehabcentercare22@gmail.com

3618 Lantana Rd, Suite 202

Lake Worth, FL 33462

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