ADVANCED REHABILITATION CLINICS, INC.
WOMEN’S HEALTH CENTER
PHYSICAL THERAPY ORDERS

PATIENT NAME__________________________________DATE________________

DIAGNOSIS:

Pelvic Floor Muscle Weakness (728.2) Status post Mastectomy
Pelvic Floor Pain (729.1) Status post C-section
Pelvic Floor Muscle Spasm (728.85) Status post Hysterectomy
    
Sciatica (724.3) Osteoporosis (733.00)
Low Back Pain (724.5) Fibromyalgia (729.1)
Sacroiliac Dysfunction (739.4) Posture Imbalance (729.3)
Diastasis Recti (665.8) Piriformis Syndrome
Neck Pain (723.1)
Other____________________________________________________________

TREATMENT:

Evaluate and Treat
Therapeutic Exercise OB Back School
Biofeedback Prenatal Exercise
Electrical Stimulation Postpartum Exercise
Postural Education
Modalities per therapist discretion

ADDITIONAL INSTRUCTIONS:__________________________________________
________________________________________________________________________

FREQUENCY/DURATION:
at therapist’s discretion
______ times per week for _______ weeks

Physician Name:____________________________________
Physician Signature:_________________________________

IN MAKING THIS REFERRAL, PHYSICIAN CERTIFIES THAT PRESCRIBED REHABILITATION IS A MEDICAL NECESSITY.
ARC - Advanced Rehabilitation Clinics Inc.
Physical Therapy, Orthopedic Physical Therapy and Rehabilitation Clinics
in Chicago and Suburbs
533 W. North Avenue, Suite 202, Elmhurst, IL 60126 (630) 832-6919 Fax (630) 832-6928
800 S. Wells Street, Suite M-5, Chicago, IL 60607 (312) 431-7610 Fax (312) 431-7644
137 Plaza Drive, Westmont, IL 60559 (630) 323-8646 Fax (630) 323-8656
3540 Seven Bridges Drive, Suite 240, Woodridge, IL 60517 (630) 968-3154 Fax (630) 968-3224
1 Tower Lane, LL, Oakbrook Terrace, IL 60181 (630) 954-0492 Fax (630) 954-0493
77 West Wacker, Mezzanine 3, Chicago, IL 60601 (312) 201-0467 Fax (312) 201-0469
8750 W. Bryn Mawr, Chicago, IL 60631 (773) 864-9452 Fax (773) 864-9448
4225 Naperville Road, Lisle, IL 60532 (630) 577-6920 Fax (630) 577-6930