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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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Protocol
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Level 1: Isometric [Cervical Spine (Neck)] Stabilization
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Level 1: Isometric for Cervical Disc Replacement
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Level 2: Isometric with Gentle Stretching [Cervical Spine (Neck)] Stabilization/Strengthening
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Level 3: Challenging ROM [Cervical Spine (Neck)] Stabilization/Strengthening
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Level 0: Hyperextension (TL)
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Level 1: Isometric [Thoracolumbar Spine (Trunk and Core)] Stabilization
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Level 2: Isometric with Gentle Stretching [Thoracolumbar Spine (Trunk and Core)] Stabilization/Strengthening
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Level 3: Challenging ROM [Thoracolumbar Spine (Trunk and Core)] Stabilization/Strengthening
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Other/ Notes
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Acupuncture
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Chiropractor
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Physician Information (Bhamb)
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