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AFRICMED INTERNATIONAL HOSPITALS

Physiotherapy care chiropractic care TMJ Evaluation Sports Evaluation Massage

PATIENT NAME____________________________________________________________________

PHONE NUMBER____________ AGE______ SEX_______PATIENT NUMBER___________________

DIAGNOSIS________________________________________________________________________

SECONDARY DIAGNOSIS / PRECAUTIONS________________________________________________

X-RAY /MRI /CT SCAN ETC RESULTS_____________________________________________________

Modalities Treatment
Ultrasound Evaluate & Treat
Electrical Stimulation Back & Neck Therapy
Vasopneumatic Ice Compression Sports Therapy
Kinesiotape Hand Therapy
Custom Splinting
Manuel Therapy Post-Op Rehab
Myofascial Release __________________
Lumbar Traction Goals
Graston Technique
RIP/PNF Stretching Relieve Pain
Joint Mobilization Restore Function
Teach Self- Treatment
Therapeutic Exercise Improve Body Mechanics
Corrective exercise Increase Strength
Core / Spine Stability Enhance Range of Motion
Improve ROM ____________________
Neuromuscular Re-education
Functional Assessment
Balance / Gait analysis
Biomechanics Evaluation
Ergonomics Postural
TMJ
Comments: ___________________________________________________________________________

Frequency/Duration: 2WKS 4WKS 6WKS 8WKS ____________________________________________

I certify that this patient is under my care and requires the listed care above

Physician Signature: ____________________________________________________________________

Brusubi, West Coast Region, The Gambia, P. O. Box 746 Banjul


Tel: (220) 4410685/7332101/7739415 Fax: (220) 4410686
E-mail:info@africmed-gm.com

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