Physical Therapy Evaluation Form

Physical Therapy Evaluation Form
Name
First NameLast Name
Date of Birth
MonthDayYear
Date
Age
Gender
MaleFemale
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Occupation
Company Name
Marital Status
SingleMarriedDivorcedWidowed
What are the initial complaints of the patient?
When did the patient get this injuries/symptoms?
MonthDayYear
Date
Please explain how did this injury happened?
Did the patient received any medical treatment, therapy, or surgery for this?
YesNo
When did the patient start the treatment or therapy?
MonthDayYear
Date
If the patient undergo any surgery related to this injury, please specify the date:
MonthDayYear
Date
Kindly rate the condition of the treatment or therapy? From 0 = worse and 5 = excellent

1
2
3
4
5
1 is Worst, 5 is Best
Kindly rate the pain the patient is experiencing: 0 = No pain at all / 10 = Extremely painful

1
2
3
4
5
6
7
8
9
10
1 is Worst, 10 is Best
Responsiveness
AlertLethargicResponds to verbal expressionReacts to painful stimuliNon-responsive
Orientation
NamePlaceTimeAgitationFollow commandsResponds to stimuliConfused
Safety Awareness
GoodFairPoor
Please select the activities that makes the condition worse?
SittingStandingWalkingRunningRestingBendingSneezeCoughMorningAfternoonEveningMedicationOther
ROM: Upper Extremities - Please list the body part and the condition. Example: Left (Good, Fair, Poor).
Body Part Left Right Strength
1
2
3
4
5
ROM: Lower Extremities - Please list the body part and the condition. Example: Left (Good, Fair, Poor).
Body Part Left Right Strength
1
2
3
4
5
What are the medications the patient is currently taking?
Does the patient have any allergies? Please list them below:
If the patient have been previously hospitalized, please provide the reason and the year.
Kindly check the following medical conditions that the patient have
Swallowing difficultyMotion sicknessStrokeArthritisFeverOsteoporosisHigh blood pressureUnexplained weight lossAnemiaCardiovascular problemsBlood clotsShortness of breathHIV/HepatitisEpilepsy/SeizuresSmoking historyDrinking alcohol historyDiabetesDepression/AnxietyMyofascial painFibromyalgiaPregnancyOther
What does patient want to achieve from therapy?
What is the current treatment plan?
What are the current clinical goals?
Physical Therapist Name
First NameLast Name
Phone Number of Physical Therapist
Please enter a valid phone number.
Email Address of the Physical Therapist
example@example.com
Physical Therapist Signature
Clear
Date Signed
MonthDayYear
Date
Should be Empty:

	Body Part	Left	Right	Strength
1
2
3
4
5

	Body Part	Left	Right	Strength
1
2
3
4
5