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Physical Therapy Rx
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Referral Order Information
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Post Procedure Protocol
• • •
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Region
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Diagnosis
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Acuity
• • •
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Orthosis/Bracing
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Frequency
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Notes
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Focus
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Soft Tissue
• • •
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Soft Tissue Notes
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ROM
• • •
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ROM Notes
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Strengthening
• • •
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Strengthening Notes
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Restrictions
• • •
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Restriction Notes
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