PERMINTAAN FISIOTERAPI

Jakarta, ................................20..........

Dengan hormat,

Bersama ini saya kirimkan pasien dengan :

Nama: ..........................................................................................................( L / P )Umur: .....................................................................................................................

No.RM: .....................................................................................................................

Diagnosis: .....................................................................................................................Harap diberikan Fisioterapi *) :

Ultra-sonic Therapy

U.K.G (Short Wave Diathermy)

Faradisasi/ Galvanisasi

Infra red/ Sollux Radiation

Ultra Violet Radiation

Traction : a. Cervical

b. Lumbal

Muscle Test

Massage

Exercises : a. Pra/ Post Natal

b. Passive

c. Active

d. Breathing

e. Postural drainage

f. Correction Posture

g. Walking

Catatan : ................................................................................................................................................................................................................................................................................................................

Jakarta, .........................20.....

dr._____________________

Ket : *) Beri tanda sesuai pilihan (nama jelas)Jln. Pluit Raya No.2

Jakarta Utara 14440

(021) 6606127

J