MILILANI PHYSICAL THERAPY, LLC

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					                            MILILANI PHYSICAL THERAPY, LLC
                                    95-720 Lanikuhana Ave, #140
                                       Mililani, Hawaii 96789
                                   Phone: 623-6244 Fax: 623-6414
Jessica DiRusso, DPT                                                              Jinky Molina, PT
Lita Endaya, PT                                                                   Kyle Ohtani, DPT
Lynne Estabilio, PT                                                               Griffith T. Yanagi, PT
Tammie Harada, PT                                                                 Grace Mariano, LMT
Mary Lau-Miki, DPT                                                                Lindsey Simmons, MPT
                                                                                  Francie Yester, LMT

               PHYSICAL THERAPY PRESCRIPTION / TREATMENT PLAN

Patient’s Name:                                       Phone:
Type of Insurance: ___ Work Comp.         ___ No Fault ___ Medicare ___ HMSA ___ Other
Insurance Company:                                           Claim#
Referring Physician:                                         Phone:
Diagnosis:                                                   Date of Injury/Onset: _____________
Special instructions:                                        Date of Surgery:

 PHYSICAL THERAPY EVALUATION AND TREATMENT                                    HOME PROGRAM
 MASSAGE THERAPY  MOBILE PHYSICAL THERAPY
MODALITIES:         Moist Heat / Cold             Ultrasound                  Electrical Stimulation
                    Iontophoresis                 TENS                        Biofeedback

PROCEDURES:  Cervical / Lumbar Traction  Myofascial Release                   Range of Motion
             Joint Mobilization          Soft Tissue Mobilization              Active / Passive
             Spinal Mobilization         Massage                              Stretching
                                          Craniosacral                         Stabilization
                                          Myotherapy                           Strength/Conditioning
                                                                                Resistive Exercise

SPECIALIZED PROGRAMS:  Neck          Hip                                      Osteoporosis
                       Back          Knee                                     Incontinence
                       Shoulder      Ankle/Foot                               Post-Surgical Breast
                       Elbow                                                     Program
                       Wrist/hand  Stroke Rehab                               Lymphedema
                       Other: ______________________                           Pelvic Floor Rehab

FUNCTIONAL TRAINING:             Gait Training       Work Hardening           Back School

EQUIPMENT/SUPPLIES:            __________________________________________________________

=====================================================================
MEASUREABLE OBJECTIVES / GOALS:        Please refer to enclosed report
FREQUENCY:  daily      1x/week  2x/week  3x/week
DURATION:        weeks / months.

Number of sessions:                               Cost Estimate:        per insurance fee schedule__
Estimated date of termination:                    Period to Cover:


                 Physician’s Signature                                               Date

				
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