Please FAX PRESCRIPTION to 946-9559 and we will schedule the patient Ala Moana Building,1441 Kapiolani Bvd Suite1113 * Honolulu HI 96814 * Phone:808-218 3660 Fax:808-946 9559 handsonpt@mac.com www.hawaiihandson.com Office Hours: 7am -7pm Monday to Saturday PHYSICAL THERAPY PRESCRIPTION Name …………………………………………………………………………………………… DOB …………………………………………………………………………………………… Diagnosis / ICD-9 code …………………………………………………………………………………………… Date of onset/ surgery …………………………………………………………………………………………… Insurance of patient: Frequency/ # of visits □ EVALUATE ………………………………………… OR □ Cash Paying patient …….times per week for total of …….visits □ OR & TREAT as per PT discretion □ CONTINUATION OF PT _____________________________________________________________________________________ MODALITIES & MANUAL THERAPY THERAPEUTIC EXERCISE & □ EMG Biofeedback □ Joint □ ROM (active, active assisted, passive) □ Electrical stimulation □ Lumbar spine mobilization □ Progressive Resisted / Strengthening □ Ultrasound □ Cervical spine □ Lumbar Stabilization / Core strengthening □ Hot / Cold packs □ Thoracic spine mobilization □ Home Tens unit □ Sacro-illiac joint / Sacral / Coccyx □ Gait training OTHER SUPPLIES mobilization ……………………. mobilization REHABILITATION □ Proprioception & Balance training Conditioning □ □ Customized Orthotics □ Soft Tissue/ Myofascial release □ McConnell /KT Taping □ Strain/Counter-strain/ □ Back Support Pillow □ Other……………………... NAGS/SNAGS □ TMJ □ Tension headaches □Traction □Other…………………… □ Home exercise program / Training advice □ □ Video Analysis and Feedback □Posture evaluation/advice □ Pelvic Floor Program Special Instructions / Recommendations: ………………………………………………………………………… ………………………………………………………………………………………………………………………………… Date …………………………... Physician Signature: ………………………………………………………… Physician Name: ……………………………………………………………….. ***Please provide patient’s telephone number(s) for scheduling …………………………