Refer a patient

Patient's Name: Date:

Diagnosis:

Surgical Procedure:

Date of Procedure:

Precautions:

PHYSICAL THERAPY ORDER

  1. Evaluate and Treat
  2. Modalities
    1. Cold/Heat
    2. Iontophoresis
    3. Ultrasound
    4. Phonophoresis
    5. Electrical Stimulation/Interferential
  3. Manual Therapy/Mobilization
  4. Therapeutic Exercises
    1. Range of Motion
    2. Spine Stabilization
    3. Flexibility Exercises
    4. ACL Protocol
    5. Strengthening Exercises
    6. Gait Training
    7. Patellofemoral Rehabilitation
    8. Functional Mobility Training
    9. Rotator Cuff Rehabilitation
  5. Home Exercise Program
  6. Postoperative Protocol
  7. Therapist Discretion
Treatment Frequency: times per week

Duration: weeks

Physician's Name:

Telephone:

UPIN Number: