M
Physical Therapy Aurora Location
Bolingbrook Location
2340 South Eola Road Phone: 630-978-9200 Fax: 630-978-9201
1337 Lily Cache Lane Phone: 630-226-5110 Fax: 630-226-5120
Plainfield Location
Lemont Location
12640 S. Route 59 Suite 110 Phone: 815-676-3900 Fax: 815-676-3901
15947 W. 127th Street Suite E Phone: 877-424-7820 Fax: 866-964-8489
Patient Name:
Diagnosis:
Precautions: Evaluate and Treat Ultrasound Electrical Stimulation
Hot Packs
Cold Packs
Phonophoresis
Iontophoresis Joint Mobilization
Soft Tissue Mobilization
Traction
Frequency and Duration:
Range of Motion Passive
Active Assisted Active
Body Mechanics/ Ergonomic Instruction
Strengthening
Home Exercise Instruction
Gait
Work Conditioning
Balance/ Proprioception Trunk Stabilization
Postural Exercise and Instruction
Other:
per therapist discretion times per week for
weeks
Signature: Date: By my signature, I hereby certify that the above is medically necessary
www.momentumphysicaltherapy.com