Mililani Physical Therapy, LLC - Mililani Physical Therapy ...
Mililani Physical Therapy, LLC95-720 Lanikuhana Ave, #140Mililani, Hawaii 96789Phone: 623-6244 Fax: 623-6414Vanessa Dasalla, PT, DPTLita Endaya, PTLynne Estabilio, PTTammie Harada, PTJessica Johnson, PT, DPTJaymee Kau, PT DPTMary Lau-Miki, PT, DPTMark Miki, PT, DPT, OCS, CSCSJinky Nisperos, PT, DPTSheyenne Turk, PT, DPTRuby Jones, LMTKimiko Miyake, LMTIvy Rivera, LMTNelson Yoshida, LMTDevyn Brubaker, LMTPhysical Therapy Prescription / Treatment PlanPatient’s Name: FORMTEXT ????? Phone: Type of Insurance: ? Work Comp ? No Fault ? Medicare ? HMSA ?OtherInsurance Company: Claim#: Referring Physician: FORMTEXT ????? Phone: Diagnosis: FORMTEXT ?????Date of Injury: Special Instructions: Date of Surgery: ? Physical Therapy Evaluation and Treatment ? Massage Therapy? Mobile Physical Therapy? Home ProgramModalities:Procedures:Specialized Programs:? Moist Heat / ColdManual Therapy:? Neck? Iontophoresis?Cervical / Lumbar Traction? Back? Ultrasound ? Joint Mobilization? Shoulder? TENS? Spinal Mobilization? Elbow? Electrical Stimulation? Manual Lymph Drainage? Wrist/hand? Biofeedback? Myofascial Release? Hip? Soft Tissue Mobilization? Knee? Massage? Ankle/Foot? Myotherapy? Vestibular RehabEquipment / Supplies:Therapeutic Exercises:? Stroke Rehab? Please list:? Range of Motion? Gait Training Active / Passive? Osteoporosis? Stretching? Incontinence? Stabilization? Post-Surgical Breast Program? Strength/Conditioning? Lymphedema? Resistive Exercise? Pelvic Floor Rehab? Other: Measurable Objectives / Goals: Please refer to enclosed reportFrequency: ? daily ? 1x/week ? 2x/week ? 3x/weekDuration: _____ ? weeks / ? months.Number of sessions: FORMTEXT ????? FORMTEXT ?????Cost Estimate: per insurance fee scheduleEstimated date of termination:Period to Cover: toPhysician’s SignatureDate ................
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