|
PT PRESCRIPTION
|
|
|
Diagnosis
• • •
|
Other Diagnosis
|
|
Status Post Sx?
|
Type of Surgery
|
|
Date of Surgery/Injury
|
|
|
Frequency
|
|
|
Insurance
|
|
|
Body Parts to Include
• • •
|
|
|
Treatment Procedures
|
|
|
Evaluate and Treat
|
Therapeutic Exercise
|
|
Modalities
|
Other:
|
|
Physician Information
|
|
