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

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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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Advantage TherapyOzark - Suite B5528 N FarmersBranch RoadOzark, MO 65721*Take theLambert’s Exit

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