PHYSICAL THERAPY
PROVIDER INFORMATION
Therapist’ s Name:
Clinic Name / Hospital Affiliation:
Clinic Address:
Phone:
Email:
Most recent start date: / / End date: / /
PHYSICAL THERAPY ROUTINE
Please describe any physical therapy practice routines or instructions that you are currently using:
Physical Therapy Home Practice
Reflect on how you want physical therapy to address your needs. All exercises should be done in a safe environment and with the monitoring and assistance of a care partner, physical therapist or exercise professional.
The following are general examples of seated exercises commonly prescribed for home programs:
Posture and Mobility:
• Roll your head in clockwise and counterclockwise circles( 10x)
• Reach your arms back as far as you can, then give yourself a big hug( 10x)
Strength:
• Put your hands on the armrests of a chair. Then straighten your elbows and lift your bottom( 5x)
• Perform alternating marches and hold your leg as high as possible for 1 – 2 seconds( 10x)
Standing exercises may be feasible for at-home workouts. A healthcare professional will help identify the necessary equipment and setup to safely exercise. Care partner training is always encouraged, too.
Standing Balance:
• Place your feet wide and perform a squat to a chair( 10x)
• Perform alternating marches with a brief pause at the top of the march( 10x)
Walking Balance:
• Use a counter or device for support; practice large, single steps to the left and right
• Place supports on either side; practice a large step backward and return to the starting position
CurePSP Prepare to Care 25