dta0yqvfnusiq.cloudfront.net · Web viewHHWC North Lakes Area Phone: 218-568-5648 Fax: 218-568-5698...

Exercise/Fitness___ Posture/Body Mechanics___ Stretching/Flexibility___ Passive ROM___ Active/Assistive ROM___ Balance/Stability Training___ Proprioceptive Exercise Training___ Core Strengthening___ Stabilization/Strengthening___ Home Exercise Program___ Progressive Fitness___ Return to Sports Rehab ______________________ Other: ________________________________________________________________

Hopkins Health & WellnessPhone: 952-933-5085

Fax: 952-931-2159PT@HopkinsWellness.com15 8th Avenue NorthHopkins, MN 55343

Name: _________________________________________________________Date of Birth: _____________________

Diagnosis: ___________________________________________ Dx Codes: ___________________________________

Onset/DOI: ____________________ Insurance: ___________________ Phone Number: _______________________

Evaluate & Treat Frequency: _____/wk Duration: _____ Weeks Total Visits: _____ __________________________General Physical Therapy & Sports Rehabilitation

Manual Therapy___ Dynamic Muscle Technique (DMT)___ Active Release Therapy (ART)___ Craniosacral Therapy___ Myofacial Release___ Deep Tissue Release___ Trigger Point Release___ Motion Assisted Muscle Release___ Soft Tissue Mobilization___ Integrated Progressive Mobilization (IPM)___ Spinal Manipulative Therapy

Modalities, Braces & Supplies___ Cold Laser___ Traction Cervical Lumbar___ Ultrasound___ Interferential E Stim___ Game Ready___ Kinesiotaping___ Brace/Support: ________________ Tens Unit___ Orthotics___ Home Traction Cerv Lumb

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Other Services Chiropractic Integrated Progressive Mobilization (IPM)Massage Therapy Deep Tissue Sports Myofacial CraniosacralDry NeedlingArea: _________________________________________

This form is a Prescription and a Statement of Medical Necessity and is valid with any licensed physical therapist in Minnesota.

Physician Name: _______________________________

Signature: ________________________Date: _______

Clinic: ___________________ Fax: ________________

DMR Clinic WoodburyPhone: 651-621-8803

Fax: 651-757-4099Darak@DMRwoodbury.com

1687 Woodlane Drive, Suite 201Woodbury, MN 55125

Lumbar Cervical Other: _________________________________________________________________

Acute Chronic

Limited (6-12 visits) strain/sprains, non-radicular pain, minor sports injuries

Progressed (12-20 visits) facet syndrome, headaches, sciatica, cervicobrachial syndrome

Advanced (20-24 visits) disc herniation, DDD, spondylolisthesis, stenosis, post-operative

Special instructions: __________________________________________________________________________

DMR Method Evaluate and Treat DMR Method

HHWC North Lakes AreaPhone: 218-568-5648

Fax: 218-568-5698Frontdesk@Lakeswellness.com31108 Government Drive Pequot Lakes, MN 56472