PT/OT Prescription date:____________________ patient: ______________________________ phone: ________________________ diagnosis: _____________________________________________________________ frequency & duration therapist discretion 1 2 3 4 5 days/week (circle one) number of weeks: ______ comments / precautions __________________________________ __________________________________ __________________________________ services offered evaluations balance program chronic pain functional capacity evaluation pneumex postural wheelchair assessment exercise AROM dynamic lumbar stab nerve gliding neuro-reeducation PROM strengthening pneumex back program modalities alpha-stim anodyne electrical stimulation biomodulator fluidotherapy ice-heat iontophoresis microlight laser ondamed paraffin phonophoresis T.E.N.S. ultrasound whirlpool traction manual therapy active release technique ASTYM manual lymphatic drainage massage muscle energy technique myofacial release nerve-mobilization pain neutralization technique primal reflex release technique spray & stretch strain-counterstrain total motion release visceral manipulation splinting/bracing gel shell SI belt prefabricated custom dynamic ankle hand/wrist elbow knee treatment goals increase ROM increase strength improve balance improve function decrease pain decrease edema home program return to work return to sports programs post-op rehab home program rotator cuff repair pain management spine ACL reconstruction total joint replacement tendinitis / tendinosis work conditioning TMJ dysfunction LSVT BIG program Biodex balance program physician signature _________________________________________________ Thank you for choosing Advantage Therapy as your rehab provider. 2017 W. Woodland St. Springfield, MO 65807 Phone: 417-889-4800 Fax: 417-889-0980 1845 E. Turner St., Ste E SOUTH SPRINGFIELD NORTH SPRINGFIELD Springfield, MO 65803 Phone: 417-864-5800 Fax: 417-864-5803 Se Habla Español MONETT 864 E. US Hwy 60, Ste A Monett, MO 65708 Phone: 417-635-1185 Fax: 417-635-1187 5528 N. Farmers Branch Rd., Ste B OZARK Ozark, MO 65721 Phone: 417-889-4800 Fax: 417-889-0980
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PT/OT Prescription date:____________________
patient: ______________________________ phone: ________________________
diagnosis: _____________________________________________________________
frequency & duration
therapist discretion
1 2 3 4 5 days/week (circle one)
number of weeks: ______
comments / precautions______________________________________________________________________________________________________
services offered
evaluationsbalance programchronic pain functional capacity evaluationpneumex posturalwheelchair assessment
exerciseAROMdynamic lumbar stabnerve glidingneuro-reeducationPROMstrengtheningpneumex back program
modalitiesalpha-stimanodyne
electrical stimulationbiomodulator
fluidotherapyice-heationtophoresismicrolight laserondamedparaffinphonophoresisT.E.N.S.ultrasoundwhirlpooltraction
manual therapyactive release techniqueASTYMmanual lymphatic drainagemassagemuscle energy techniquemyofacial releasenerve-mobilizationpain neutralization techniqueprimal reflex release techniquespray & stretchstrain-counterstraintotal motion releasevisceral manipulation
splinting/bracinggel shellSI beltprefabricatedcustomdynamicanklehand/wristelbowknee
treatment goals increase ROM increase strength improve balance
improve function decrease pain decrease edema
home program return to work return to sports
programs post-op rehab home program rotator cuff repair pain management
spine
ACL reconstruction total joint replacement tendinitis / tendinosis work conditioning TMJ dysfunction
LSVT BIG program Biodex balance program
physician signature _________________________________________________
Thank you for choosing Advantage Therapy as your rehab provider.
2017 W. Woodland St.
Springfield, MO 65807
Phone: 417-889-4800
Fax: 417-889-0980
1845 E. Turner St., Ste E
SOUTH SPRINGFIELD NORTH SPRINGFIELD
Springfield, MO 65803
Phone: 417-864-5800
Fax: 417-864-5803
Se Habla Español
MONETT
864 E. US Hwy 60, Ste A
Monett, MO 65708
Phone: 417-635-1185
Fax: 417-635-1187
5528 N. Farmers Branch Rd., Ste B
OZARK
Ozark, MO 65721
Phone: 417-889-4800
Fax: 417-889-0980
I-44
Hwy 60
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Battlefield
Sunshine
Kearney
Sunset
Woodland
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SPRINGFIELD
Advantage Therapy
Advantage TherapyMonett - Suite A864 E. US Hwy 60Monett, MO 65708Located nearBayou Restaurant
2017 W. Woodland St.Springfield, MO 65807
Advantage Therapy - NorthLocated near Kmart1845 E. Turner St, Ste ESpringfield, MO 65803
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l Dr.
Bri
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Ln.
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HWY 60
MONETT
Advantage TherapyOzark - Suite B5528 N FarmersBranch RoadOzark, MO 65721*Take theLambert’s Exit
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N. F
arm
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/ HW
Y N
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7th
St.
Hwy CC / J
OZARK
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