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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: [email protected] 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: [email protected]
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: [email protected] Government Drive Pequot Lakes, MN 56472
