Script Pad DOWNLOAD FORM HERE OR FILL HERE Patient(Required)Date(Required)Diagnosis(Required)Demographics Attached(Required) Yes No Treatment Procedures Evaluate and treat for physical therapyTherapeutic Exercise(Required) ROM ROM - Passive ____Weeks ROM - Active-Assistive ____ Weeks ROM - Active ____Weeks Strength Training Aerobic Conditioning Dynamic Trunk Stabilization McKenzie Method Balance/Coordination Back Program Modalities(Required) Electrical Stimulation Ultrasound NMES Iontophoresis Cold Laser Moist Heat/Cold TENS Unit ROM - Passive How Many Weeks(Required)ROM - Active-Assistive How Many Weeks(Required)Active How Many Weeks(Required)Patient Education(Required) Postural Awareness ADL Modification Ergonomic Advice Preventive Advice Manual Therapy(Required) Joint Mobilization Soft Tissue Mobilization Specialized Services(Required) Mechanical Traction Dry Needling Cupping Aquatic Therapy Special Instructions/Precautions(Required)Frequency Per Week(Required) 1 2 3 Daily Please ChooseDuration(Required) 1 2 3 4 5 6 Please ChooseNext Office Visit(Required)Choose Attached(Required) X-Ray MRI Physician's Notes Operative Report Physician Signature(Required)I hereby certify the above services have been Reminder: Please bring this referral slip with you on your first visit Please arrive 15 minutes before your scheduled appointment to complete the necessary paperwork or access forms online at www.bodyworxpt.com Evaluations (1st visit) usually last 45 minutes – 1 hour What to wear: Please wear/bring comfortable clothing and sneakers including T-shirts and shorts or sweatpants What to bring: Driver’s license Current insurance card(s) or workers’ compensation employer information including claim number </noscript><iframe class="lazy" style='display:none;width:0px;height:0px;' src="" data-src='about:blank' name='gform_ajax_frame_5' id='gform_ajax_frame_5' title='This iframe contains the logic required to handle Ajax powered Gravity Forms.'> CALL FOR AN APPOINTMENT: 405-253-5076 Fax: 405-253-5683 Email:info@bodyworxpt.com Follow Us </noscript><iframe class="lazy" src="" data-src="https://www.google.com/maps/embed/v1/place?q=Bodyworx+8809+S+Sooner+Rd.+Suite+E+Oklahoma+City%2C+Oklahoma+73135&key=AIzaSyD09zQ9PNDNNy9TadMuzRV_UsPUoWKntt8" aria-hidden="true"> </noscript><iframe class="lazy" src="" data-src="https://www.google.com/maps/embed/v1/place?q=4019+North+Flood+Ave%0ANorman%2C+OK+73069%0A&key=AIzaSyD09zQ9PNDNNy9TadMuzRV_UsPUoWKntt8" aria-hidden="true"> </noscript><iframe class="lazy" src="" data-src="https://www.google.com/maps/embed/v1/place?q=Bodyworx+201+S+Sara+Rd%2C+Suite+150+Mustang%2C+OK+73064&key=AIzaSyD09zQ9PNDNNy9TadMuzRV_UsPUoWKntt8" aria-hidden="true">
