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Farshid Farajzadeh, M.S., P.T.
Physical Therapist

Ocean Physical Therapy
4501 Mission Bay Drive, Suite 3K
San Diego, California 92109

858.866.0340 PHONE
858.866.0342 FAX
   

Patient's Name         Date

Diagnosis        ICD-9

Specific Instructions (if needed)
           

 
 Evaluate and Treat (as needed)
 
  Manual Therapy - Mobilization
  Soft Tissue Massage - Mobilization
  Therapeutic Exercise - Active -
        Passive - Resistive - Functional
  Gait Training
  Traction (manual) - Cervical - Pelvic -
        Extremities
  Simulated Work Hardening - Conditioning
  Other (specify)
 
 
  Joint Mobilization
  Neuromuscular Re-education
  Electrical Stimulation - Pain Control
  Ultrasound
  Cold Pack
  Heat Pack
  Custom Foot Orthotics
 
Frequency  per week for weeks
 
 

Physician's Signature

Print Name         Lic / UPIN #