INJURY/FITNESS REHAB PRESCRIPTION FORM

NAME: ______________________ DATE: ______________

Injury (If applicable):

Date of Injury:

Past treatment including Physical Therapy:

• [ ] Physical Therapy
• [ ] Peer Fitness Trainer

Rehab Prescription:

Prepare for P.A.T Lab with practice on:

• [ ] 3 Minute Step Test
• [ ] Hose Pull
• [ ] Equipment Carry
• [ ] Ladder Raise
• [ ] Forcible Entry
• [ ] Crawling
• [ ] Hose Advance
• [ ] Ceiling Breech and Pull
• [ ] Rescue

• [ ] Doctor
• [ ] Physical Therapist

Signature: _________________________________