Page 1

M

Physical Therapy Aurora Location

Bolingbrook Location

2340 South Eola Road Phone: 630-978-9200 Fax: 630-978-9201

1337 Lily Cache Lane Phone: 630-226-5110 Fax: 630-226-5120

Plainfield Location

Lemont Location

12640 S. Route 59 Suite 110 Phone: 815-676-3900 Fax: 815-676-3901

15947 W. 127th Street Suite E Phone: 877-424-7820 Fax: 866-964-8489

Patient Name:

Diagnosis:

Precautions: Evaluate and Treat Ultrasound Electrical Stimulation

Hot Packs

Cold Packs

Phonophoresis

Iontophoresis Joint Mobilization

Soft Tissue Mobilization

Traction

Frequency and Duration:

Range of Motion Passive

Active Assisted Active

Body Mechanics/ Ergonomic Instruction

Strengthening

Home Exercise Instruction

Gait

Work Conditioning

Balance/ Proprioception Trunk Stabilization

Postural Exercise and Instruction

Other:

per therapist discretion times per week for

weeks

Signature: Date: By my signature, I hereby certify that the above is medically necessary

www.momentumphysicaltherapy.com

Knizner_Adam_frontofnotepad  

Range of Motion Passive Active Assisted Active Strengthening Balance/ Proprioception Gait Trunk Stabilization Postural Exercise and Instruct...

Read more
Read more
Similar to
Popular now
Just for you