PHYSICIAN ORDER PHYSICIAN ORDER* Physical Therapy Evaluation and Treatment Vestibular Rehab Cardiovascular Physical Therapy Pulmonary Physical Therapy Balance Retraining Patient Name:*Phone #:*Age:*DOB:* Date Format: DD slash MM slash YYYY Referring Physician:Phone #:Fax #:Diagnosis:Pulmonary:* COPD Pulmonary Fibrosis Cystic Fibrosis HVS Lung volume reduction Lung surgery Lung Transplant Restrictive lung disease Asthma Bronchiectasis Cardiovascular:* AMI CABG X Stable Angina Valve replacement type PTCA Stent Pacemaker/ICD Heart Transplant Stable CHF PAD Other: CABG XOther:Date of Onset:*Untitled* Sternal Precautions EF (most recent) EF (most recent) EF (most recent) ....... %Comorbidities:Date of Surgery: Date Format: DD slash MM slash YYYY Exercise Test Results attached N / Y Date: Date Format: DD slash MM slash YYYY Medication list attached N / Y PFT: Date: Date Format: DD slash MM slash YYYY FEV1*FEV1/FVCPEFR*Duration:*Frequency:*Total Sessions:*Special Considerations/Precautions: Fall Risk Osteoporosis Low Back Pain Joint Replacement Other OtherSupplemental Oxygen*Titrate supplemental O2 to maintain SpO2% >*Include the Following in the Treatment Program:* Endurance Training Submaximal Ex. Testing Balance Training Breathing Retraining Inspiratory Muscle Training ACBT Postural Drainage/CPT Autogenic drainage Relaxation Technique Functional Retraining Neuromuscular re-ed Chest Clearance Devices PEP mask / Flutter / Cornet / Accapella / TheraPEP / EZPAP / IS I certify the above Physical Therapy treatment to be medically necessary. Physician Signature:*Date:* Date Format: DD slash MM slash YYYY
