1919 West Huguenot Rd
Suite 202
Richmond, VA 23235
(phone) 804.379.3002
(fax) 804.379.3053
www.obgyn-physicaltherapy.com
Cora T. Huitt, MA, PT
Angela A. Poole, LPTA
Maggie Benbeneck, CMT
Date _______________________________ Authorization # __________________________
Patient’s Name ________________________ Address _______________________________
Home Phone __________________________ Work Phone ___________________________
Diagnosis:
Abdominal/Groin Pain (789.0)
Abdominal Deficiency (756.79)
Anal/rectal pain (569.42)
Carpal tunnel Syndrome (354.0)
Constipation (564.0)
 Coccygodynia/Coccydnia (724.79)
 Diastasis Recti (pregnancy) (665.84)
Disuse Atrophy (728.2)
Fibromyalgia/Myofacial pain (729.1)
Headaches (784.0)
 Interstitical Cystitis (595.1)
Fecal Incontinency (787.6)
Pain in Cervical (739.1)
 Hypertonous, Spasm of Muscles (728.85)
Incontinence Mixed (788.33)
Incontinence Stress (625.6)
Incontinence Urge (788.31)
 Osteoporosis (733.0)
 Pregnancy (V22.2)
 Postural Dysfunction (781.9)
 SIJ Dysfunction (739.4)
 Vaginismis (625.1)
 Vulvodynia (625.9)
 Sumatic Dysfunction (739.5)
Muscle Incoordination (781.3)
Pain of the Pelvis (789.9)
 Proctalgia (564.6)
Ankle Sprain (845.0)
 Lumbosacral Strain (846.0)
Shoulder Sprain (840.9)
 TMJ (524.60)
Low Back Pain (724.8)
Other:_____________________________
Rx Order and Goals:
 Evaluate and Treat
 Ultrasound
 Iontophoresis
 Phonophoresis
 Electrical Stimulation
 Training in TENS/IFC/NMES for home use
 Whirlpool
 Parafin
 Moist/Cold therapy
 Joint mobilization
 Soft tissue mobilization
 Massage/manual lymph drainage
 Myofascial release techniques
 Craniosacral therapy
Frequency: PRN
qd
1x/wk
2x/wk
 Osteoporosis program
 Pre/postnatal services
 Pelvic floor rehabilitation
 Back/neck school
 Fitness program
 Work rehabilitation
 Stress management/relaxation exer.
 Massage/myofascial treatment
 Functional activities training
 Postural and body awareness act.
 Neuromuscular re-education
 Home exercise program
 Patient/family education/training
 Assess pt.’s need for DME
3x/wk for______________________________
Precautions, if any: ______________________________________________________________
Pt’s next Dr.’s visit: _________________ Physician’s Signature: ____________________