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Plan of Care · Rehabilitation

Plan #

Start

Re-Eval

Patient

Treating Therapist

Course

Assessment & baselineEval · 03/09/26

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Rehab goalsMeasurable

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Phase progression8-week roadmap

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Current exercise prescriptionSets × Reps

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Sets

Freq

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Visit schedule

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Plan agreement

I have reviewed this plan of care with my physical therapist, understand the goals and home program, and agree to participate. A copy is mine to keep.

Patient signature · Date

Dana Reyes, DPT · Date

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Visit schedule

Plan agreement