"*" indicates required fields CompanyThis field is for validation purposes and should be left unchanged.Patient Name* First Last DOB MM slash DD slash YYYY PhysicianFollow up date MM slash DD slash YYYY DiagnosisPrecautionsOrderPhysical Therapy Evaluate & Treat Aquatic Therapy Home Safety Evaluations Transfer Training Balance Training Gait Training Therapeutic Exercise Lumbar brace and fitting Small medical equipment Osteopathic PT Headache Management Dry Needling w/o Neurostimulation Nerve Conduction Studies Occupational Therapy Frequency/Duration: Manual Therapy/Joint Mob. Self Care/Home Management Home Exercise Program DME (Cane, walker, other supplies) (TENS, NMES, & IFC). Spinal manipulation / Mobs Vestibular/Concussion Therapy Electromyography Neuromuscular Re-education Orthotics Fit/Training Goals: Improve ROM Improve Strength Improve Mobility Improve Function Other OtherSignature*Date* MM slash DD slash YYYY
