Physical Therapy Initial Evaluation Form
Patient Information
Name
First Name
Last Name
Age
Height
Weight
Date of Birth
-
Month
-
Day
Year
Date
Occupation
Cellular Number
-
Area Code
Phone Number
Home Number
-
Area Code
Phone Number
Employer
Currently Employed
Yes
No
Modified
Rehab Information
Chief Complaint / Aliment / Injury
Date of Injury
-
Month
-
Day
Year
Date
Date of Surgery
-
Month
-
Day
Year
Date
Briefly Describe How You Were Injured
Have you received therapy for this condition?
Yes
No
When?
How Many Visits?
Has your condition been getting:
WORSE
SAME
BETTER
Are your symptoms:
CONSTANT
INTERMITTENT
At Best Which Number Corresponds With Your Pain
1
2
3
4
5
6
7
8
9
10
At Worse Which Number Corresponds With Your Pain
1
2
3
4
5
6
7
8
9
10
What decrease/makes your condition better?
Bending
Sitting
Rising
Changing Positions
Lying
Walking
Standing
Movement
Rest
Heat
Ice
Medication
Better In AM
Better In PM
Better as Day Progresses
N/A Cast Just Removed
What increases/makes your condition worse?
Bending
Sitting
Rising
prolonged Positioning
Worse as Day Progresses
Movement
Standing
Walking
Lying
N/A Cast Just Removed
Rest
Stairs
Cough
Worse in AM
Sneeze
Deep Breath
Medication
Worse in PM
Previous Medical Interventions
X RAY
MRI
Injections
Catscan
Other
What are your goals to be achieved by the end of therapy?
Affected Area (Body Part)
Medical Information
Difficulty Swallowing
Arthritis
High Blood Pressure
Heart Trouble
Pacemaker
Epilepsy / Seizure
History of Drug Abuse
Myofascial Pain
Cancer
Motion Sickness
Fever / Chills / Sweats
Unexplained Weight Loss
Blood Clots
Shortness of Breath
History of Smoking
Diabetes
Fibromyalgia
Stroke
Osteoporosis
Anemia
Bleeding Problems
HIV / Hepatitis
History of Alcohol Abuse
Depression / Anxiety
Pregnancy
Previous Surgeries
Medication
Allergies
Signature Of Person Completing Form
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