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PT PRESCRIPTION
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Diagnosis
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Other Diagnosis
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Status Post Sx?
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Type of Surgery
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Date of Surgery/Injury
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Frequency
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Insurance
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Body Parts to Include
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Treatment Procedures
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Evaluate and Treat
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Select all that apply
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Therapeutic Exercise
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Select all that Apply
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Modalities
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Select all that appy
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Other/ Notes
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Acupuncture
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Chiropractor
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Physician Information
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