PRESCRIPTION FORM - Hands

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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
[email protected]
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 …………………………
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