NorthBridgePT
Fax to (843) 571-0844/Phone (843) 571-0877
Patient Name:______________________________________
Patient Diagnosis:__________________________________
Precautions:_______________________________________
Date of Birth: __________________________
Phone:________________________________
Insurance:_____________________________
Treatment Parameters:
_____ Times per week _____ Number of weeks
Specific Modalities or Treatment Type:
_____ Women's Health(Pelvic Pain and Post-Natal Pain)
_____ Joint Mobilization
_____ Myofascial Release ___
_____ Complex Regional Pain Program (RSD)
_____ Fibromyalgia
_____ Breast Cancer Rehabilitation
_____ Scoliosis
Rehabilitation _____ Headache Program
_____ Osteoporosis Program
_____ Ergonomic/ Core StabilizationTraining for Neck and Back Pain
_____ Biofeedback Postural Training with Alexander Technique
_____ Prone Mechanical Traction
_____ Pelvic Floor Rehabilitation
_____ Ultrasound/Phonophoresis
_____ E-Stimulation _____ TENS Trial
_____ Iontophoresis (specificy Rx compound)
_____ Specify Orthopedic Rehab (Yoga, Golf, Runner, Ballet Dancer, Tennis, etc)
Specifics:_________________________________________________________________________
MD Signature: ______________________________
Date: ______________________________
"Physical Therapy using Balanced Body Pilates Equipment"