NASSAU (516) Glen Cove 671-6161 *East Meadow 564-9000 Garden City 741-4555 SUFFOLK (631) *East Northort 462-9595 *Smithtown 979-5900 Coram 732-3900

PHYSICAL THERAPY REFERRAL

PATIENT:___________________________________________	DATE:____________
DIAGNOSIS:___________________________________________________________
PRECAUTIONS:________________________________________________________
FREQUENCY:_______________X/week for _______ weeks

Evaluate and Contact Physician Send progress notes to M.D.

Evaluate and Test

MODALITY	EXERCISE	AQUATIC THERAPY
Hydrocollator Ultrasound Electrical Stim Ice/Compression Traction Whirlpool Massage Paraffin Iontophoresis	Passive ROM Joint Mobilization Active ROM Resistive Exercise Balance/Proprioception Isokinetic Eval. Back Stabilization Postural Re-education Neurological Re-education Gait Training	Buoyancy Assist. Protective Wt. Bearing Resist Exercise *AQUATIC EXERCISE Treadmill Recumbent Bike Cross-Country Ski Stair Stepper Skate Simulator Swim Tether

ORTHOPEDIC PROGRAMS	SPECIAL PROGRAMS
Spinal Flexibility Program Joint Replacement Protocol Osteoporosis Program Joint Instability Program Hand Therapy	Medical Recovery/Re-conditioning Neurological Evaluation Pre/Post Partum Program
Pediatric - Ortho Condition ______________________________________ Geriatric - Ortho Condition ______________________________________
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Physicians Signature	(Please Print Name)