1659 78th Street, Ste 2A
Brooklyn, NY 11214
718-234-1212
aquaticrehabilitation@gmail.com
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Referral Form
Printable Referral Form (pdf)
THERAPY REFERRAL FORM
Patient First Name:
Patient Last Name:
Date:
Patient Phone:
Diagnosis:
Precautions:
PHYSICAL/OCCUPATIONAL THERAPY
Evaluate Treat
Therapeutic Exercise (Active, Passive, AOL)
Functional Activities (Gait, Balance, AOL)
Neuromuscular Re-education
Manual Therapy (Joint & Soft Tissue Mobilization)
Modalities (Elect Stirn, Ultrasound, lontophoresis)
Thermal Modalities (Ice, Moist Heat)
Traction (Lumbar, Cervical)
Comments:
AQUATIC & SPECIALTY PROGRAMS
Activity Prescription Program
* General Exercise for Health/ Disease Prevention
* Oncology I Cancer Conditioning
* Diabetes Management through Activity
Aquatic Program
Arthritis / Prehabilitation Program
Balance / Fall Prevention
Cardiopulmonary Physical Therapy
Diabetic Peripheral Neuropathy / Anodyne
Low Back and Neck Pain
Osteoporosis Program
Post-mastectomy Care
Post-surgical Care
Prenatal Programs
* Carpal Tunnel Syndrome
* Low Back/ Pelvic Pain
Stroke Recovery Program
TMJ / Craniofascial / Headaches
Vestibular Rehabilitation
Work Injury / Return to Work
Other:
Other Treatments:
Frequency:
Duration:
MD First Name:
MD Last Name:
MD Phone:
MD Signature:
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