Physical Therapy Evaluation Form
Name
First Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Gender
Male
Female
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Company Name
Marital Status
Single
Married
Divorced
Widowed
What are the initial complaints of the patient?
When did the patient get this injuries/symptoms?
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please explain how did this injury happened?
Did the patient received any medical treatment, therapy, or surgery for this?
Yes
No
When did the patient start the treatment or therapy?
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
If the patient undergo any surgery related to this injury, please specify the date:
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Kindly rate the condition of the treatment or therapy? From 0 = worse and 5 = excellent
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Kindly rate the pain the patient is experiencing: 0 = No pain at all / 10 = Extremely painful
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Responsiveness
Alert
Lethargic
Responds to verbal expression
Reacts to painful stimuli
Non-responsive
Orientation
Name
Place
Time
Agitation
Follow commands
Responds to stimuli
Confused
Safety Awareness
Good
Fair
Poor
Please select the activities that makes the condition worse?
Sitting
Standing
Walking
Running
Resting
Bending
Sneeze
Cough
Morning
Afternoon
Evening
Medication
Other
ROM: Upper Extremities - Please list the body part and the condition. Example: Left (Good, Fair, Poor).
Rows
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).
Rows
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 difficulty
Motion sickness
Stroke
Arthritis
Fever
Osteoporosis
High blood pressure
Unexplained weight loss
Anemia
Cardiovascular problems
Blood clots
Shortness of breath
HIV/Hepatitis
Epilepsy/Seizures
Smoking history
Drinking alcohol history
Diabetes
Depression/Anxiety
Myofascial pain
Fibromyalgia
Pregnancy
Other
What does patient want to achieve from therapy?
What is the current treatment plan?
What are the current clinical goals?
Physical Therapist Name
First Name
Last Name
Phone Number of Physical Therapist
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address of the Physical Therapist
example@example.com
Physical Therapist Signature
Date Signed
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: