Physical Therapy Clinical Skills Exam Evaluation Form
Evaluate a physical therapy clinical skills exam using structured ratings for clinical performance, reasoning, safety, communication, professionalism, and overall outcome.
Examinee and Exam Details
Examinee Name
*
First Name
Last Name
Program or Cohort
*
Evaluator Name
*
Exam Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Exam Time
Hour Minutes
AM
PM
AM/PM Option
Clinical Setting or Station Name
*
Exam Version or Case Scenario Name
Core Clinical Skills Evaluation
Patient Assessment Technique
*
Unsatisfactory
1
2
3
Excellent
4
1 is Unsatisfactory, 4 is Excellent
Therapeutic Exercise Demonstration
*
Unsatisfactory
1
2
3
Excellent
4
1 is Unsatisfactory, 4 is Excellent
Manual Therapy Technique
*
Unsatisfactory
1
2
3
Excellent
4
1 is Unsatisfactory, 4 is Excellent
Gait or Mobility Training
*
Unsatisfactory
1
2
3
Excellent
4
1 is Unsatisfactory, 4 is Excellent
Patient Safety and Body Mechanics
*
Unsatisfactory
1
2
3
Excellent
4
1 is Unsatisfactory, 4 is Excellent
Infection Control
*
Unsatisfactory
1
2
3
Excellent
4
1 is Unsatisfactory, 4 is Excellent
Communication with Patient
*
Unsatisfactory
1
2
3
Excellent
4
1 is Unsatisfactory, 4 is Excellent
Professionalism
*
Unsatisfactory
1
2
3
Excellent
4
1 is Unsatisfactory, 4 is Excellent
Clinical Reasoning
*
Unsatisfactory
1
2
3
Excellent
4
1 is Unsatisfactory, 4 is Excellent
Outcome and Comments
Overall Outcome
*
Pass
Pass with Remediation
Fail
Overall Score (%)
Strengths
Areas for Improvement
Evaluator Comments / Remediation Plan
Submit Evaluation
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