Our prescription form is below...
Myofascial Release Treatment Centers:
www.myofascialrelease.com
Upledger Institute of Craniosacral Therapy:
www.upledger.com/
Real Exercise Personal Training Center:
Lake County's most experienced personal trainers
since 1977. One-on-one weight training.
www.realexercise.biz/
Our prescription form:
GANFIELD
MFR THERAPEUTICS, LTD.
Occupational Therapy/Myofascial Release
________________________________________________
Patient
________________________________________________
Working Diagnosis ICD-9 Code
________________________________________________
Precautions
TREATMENT PLAN
Comprehensive Myofascial Release
q
Evaluate
and Treat _________________________________________
q Continue Treatment __________________________________________________
q Treatment Sessions X ____10 ____15____Other
q Frequency of Treatment 1 2 3
4 5 days
q Exercise ____________________________________________________________
Active
Passive
Resistive
q Activities of Daily Living
q Modalities
q Hot Packs
q
Cryotherapy
q
Ultrasound
q
Vibration
q TNS
q Home Program
q
Splint (describe) _____________________________________________________
q
Other ______________________________________________________________
__________________________________M.D.
__________________________________Address
__________________________________Address
__________________________________Phone/Fax
Date:_____________
________________________________________________
GANFIELD
MFR
Lisa
Ganfield,OTR/L, CHT
THERAPEUTICS, LTD. Licensed Occupational Therapist
1125 N Delany Rd. And Certified Hand
Therapist
Gurnee, IL 60031 (847)
244-7070 (847) 244-7071 (Fax)
