Evaluate the patient. Vero writes it up.
Vero Scribe writes the evaluation in your template from the session conversation, with the patient’s consent, or from your dictation. You review and edit the goals and plan, then copy it into your EMR.
Physical Therapy Evaluation Template
A physical therapy evaluation sets the baseline for an episode of care: history, tests and measures, diagnosis, prognosis, goals, and the plan of care. Copy the free template, see two filled examples, and check how to write goals that are measurable and time-bound.
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- Two filled examples
Blank physical therapy evaluation template
FreePHYSICAL THERAPY EVALUATION Patient: [Name] Date of birth: [Date] Date of evaluation: [Date] Referral: [Referring clinician and reason, or direct access] Medical diagnosis: [Diagnosis from the referral or chart] Treatment diagnosis: [The movement problem you will treat] Therapist: [Name, credentials] HISTORY Chief complaint: [Main problem, in the patient's words] Current condition: [Onset, mechanism of injury, course, imaging, treatment so far] Symptoms: [Location, pain out of 10 at best and worst, 24-hour pattern, what aggravates and eases it] Medical history: [Conditions and surgeries relevant to rehab] Medications: [Medications that affect exercise, healing, bleeding, or balance] Red flag screen: [Questions asked, answers, and action taken] Social history: [Home layout and stairs, who they live with, work, activity and sport] Patient goals: [What the patient wants to get back to] PRIOR LEVEL OF FUNCTION Before this episode: [Mobility, self-care, work, sport, community activity, devices used] SYSTEMS REVIEW Cardiovascular and pulmonary: [Resting HR, BP, RR, SpO2, edema] Integumentary: [Skin, incisions, scars] Musculoskeletal: [Gross symmetry, range of motion, strength] Neuromuscular: [Gross coordination, balance, gait, transfers] Communication and cognition: [Language, orientation, learning preferences, ability to follow instructions] TESTS AND MEASURES Observation and posture: [Findings] Range of motion: [Joint and motion, active and passive, degrees, both sides] Strength: [Muscle group, manual muscle test grade out of 5 or dynamometry, both sides] Special tests: [Test, result, side] Neurological screen: [Sensation, reflexes, myotomes, tone, as indicated] Palpation and joint mobility: [Findings] Balance, gait, and transfers: [Tests and scores, device, assist level] Outcome measure: [Name and baseline score] ASSESSMENT Clinical impression: [Physical therapy diagnosis and the findings that support it] Impairments: [Body structure and function problems found] Activity limitations: [Tasks the patient can't do or does with difficulty] Participation restrictions: [Work, family, community, or sport roles affected] Factors affecting recovery: [Health conditions, psychosocial factors, supports] PROGNOSIS Rehab potential: [Good, fair, or poor, and why] Expected outcome: [Level of function expected by discharge] GOALS Short-term goal 1: [Measurable outcome, by when] Short-term goal 2: [Measurable outcome, by when] Long-term goal 1: [Functional outcome with a measure, by when] Long-term goal 2: [Functional outcome with a measure, by when] PLAN OF CARE Frequency and duration: [Visits per week, number of weeks] Planned interventions: [Therapeutic exercise, manual therapy, neuromuscular re-education, gait training, modalities, education] Home exercise program: [Exercises issued today, with dosage] Consent and agreement: [Plan explained, questions answered, patient agrees] Coordination: [Report to the referring clinician, other referrals] Discharge plan: [Where care continues after therapy] Signed: [Clinician name, credentials, date and time]
Use it for
- Initial evaluations
- Direct access visits
- Post-surgical referrals
- Neurological rehab
- New episodes of care
Two filled examples. Every part, filled in.
Each one follows the template. Use them to judge how much detail every part needs.
Physical therapy evaluation: rotator cuff tendinopathy
Outpatient clinic, referred by her family physician
History
48-year-old right-handed woman with right shoulder pain for 3 months, which started gradually after a weekend of painting ceilings. Pain over the outer upper arm, 2/10 at rest and 6/10 reaching overhead or behind her back. Wakes when lying on the right side. Works as a hairdresser, with her arms raised most of the day. X-ray normal. Takes ibuprofen as needed; hypertension, well controlled. Red flag screen: no trauma, fever, night sweats, weight loss, history of cancer, neck pain, or arm numbness. Her goals: get through a full workday and sleep through the night.
Prior level of function
Independent in all activities. Working 4 days a week. Swam twice a week until 2 months ago, when pain stopped her.
Systems review
BP 128/82, HR 72. Skin intact. Right shoulder elevation reduced; otherwise symmetrical. Gross coordination and gait normal. Communicates clearly; prefers written and demonstrated instructions.
Tests and measures
Cervical spine: full range without pain; Spurling’s test negative; upper limb sensation, reflexes, and myotomes normal. Right shoulder AROM: flexion 150°, abduction 140° with a painful arc between 60 and 120°, external rotation 70°; left full. PROM right full, with pain at end range of flexion. Strength: right external rotation 4/5 and abduction 4/5, both painful; left 5/5. Scapular dyskinesis on lowering from flexion on the right. Hawkins-Kennedy and Neer tests positive; empty can test painful with mild weakness; drop arm test and external rotation lag sign negative. Shoulder Pain and Disability Index 46%.
Assessment
Right rotator cuff related shoulder pain, consistent with tendinopathy: painful arc, pain and mild weakness on resisted external rotation and abduction, full passive range, and negative lag and drop arm tests. Neck screened out as a source. Impairments: painful active elevation, rotator cuff weakness, and reduced scapular control. Activity limitations: reaching overhead and behind the back, lying on the right side. Participation: shorter workdays, stopped swimming. In her favor: short history, good general health, and motivation.
Prognosis
Good. No signs of a full-thickness tear, a short history, and room to adapt her work tasks. Expected to return to full workdays and swimming.
Goals
Short-term, 3 weeks: sleep on the right side with pain 3/10 or less; independent with the home program. Long-term, 10 weeks: full active elevation without a painful arc; work a full day with pain 2/10 or less; SPADI under 20%; swim twice a week.
Plan of care
Once a week for 10 weeks, with the home program on other days. Progressive rotator cuff and scapular strengthening, changes to work tasks, and manual therapy for pain if needed. Home program today, daily: isometric external rotation and abduction against a wall, 5 holds of 30 s; side-lying external rotation without weight, 3 × 10. Lower the salon chair so she works below shoulder height where she can. Plan explained; she agrees. Evaluation sent to her family physician. Advised to see her physician for sudden weakness after a fall or strain, or new numbness in the arm.
Physical therapy evaluation: gait and balance after stroke
Outpatient neurological rehab, referred after inpatient rehab
History
72-year-old man, 6 weeks after a left middle cerebral artery ischemic stroke, with right-sided weakness and mild word-finding difficulty. Home from inpatient rehab 1 week ago; referred for gait and balance. One near-fall while turning in the kitchen, no falls. Says his right foot “catches” when he is tired. History: hypertension, type 2 diabetes, atrial fibrillation. Takes apixaban; no bleeding problems reported. Lives with his wife in a two-story house, 12 stairs with a rail on the right going up, bedroom upstairs. His goals: walk to the mailbox and back alone, and get back to his weekly card game.
Prior level of function
Independent without a device. Drove, did the grocery shopping, and walked 30 minutes most days.
Systems review
BP 138/84, HR 76 and irregular, SpO2 97% at rest. Skin intact; no redness from the ankle-foot orthosis. Right hemiparesis. Mild word-finding difficulty; follows 2-step commands; learns best by demonstration. Visual fields full to confrontation.
Tests and measures
Right lower limb strength: hip flexion 3+/5, knee extension 4-/5, ankle dorsiflexion 2/5; left 5/5. Modified Ashworth Scale 1 at the right plantarflexors. Light touch intact. Stands from a standard chair independently, using his arms. Gait with a single-point cane and right ankle-foot orthosis, supervision: short right step, reduced knee flexion in swing, toe catch when tired. 10-meter walk test 0.62 m/s. Timed Up and Go 19 s with the cane. Berg Balance Scale 41/56. 6-minute walk test 220 m (720 ft); BP 146/86 and HR 92 afterward, back to baseline within 3 minutes. Stairs: 12 steps with the rail, step-to pattern, contact guard assist. Activities-specific Balance Confidence Scale 52%.
Assessment
Gait and balance impairment after a left MCA stroke, from right hemiparesis with weak dorsiflexion, reduced balance, and low walking endurance. A gait speed of 0.62 m/s limits him to short community distances. Berg 41/56 and TUG 19 s point to a high fall risk, which matters more because he takes an anticoagulant. Activity limitations: walking outdoors, stairs without help, carrying things while walking. Participation: not driving, missing his card game. In his favor: motivation, steady recovery so far, and a wife who is closely involved.
Prognosis
Good for walking in the community with a cane. Early after the stroke, recovering steadily, and well supported at home. Word-finding difficulty does not limit learning by demonstration.
Goals
Short-term, 4 weeks: Berg 46/56 or higher; 12 stairs with the rail, step-to, with supervision; gait speed 0.7 m/s. Long-term, 10 weeks: walk 150 m (490 ft) to the mailbox and back with a cane, independently, on level and uneven ground; gait speed 0.8 m/s or faster; 6-minute walk 300 m (985 ft) or more; ABC Scale 67% or higher.
Plan of care
Twice a week for 10 weeks. Task-specific gait training with high repetition, balance training, lower limb strengthening, stair practice, and teaching his wife how to guard him safely. Home program today, daily: sit to stand 3 × 10, standing weight shifts at the kitchen counter 3 × 1 minute, and short indoor walks with his wife nearby. Fall prevention: a clear route to the bathroom, night lights, and the orthosis and shoes for all walking. Because of the anticoagulant, seek urgent care after any fall with a head strike; call 911 for new face drooping, arm weakness, or speech changes. Plan agreed with him and his wife; evaluation sent to his physician.
What goes in each part.
History
The patient’s story and context: how the problem started, how it behaves, what is safe to treat, and what they want back.
- Onset, mechanism, and course, with imaging and treatment so far
- Pain at best and worst, and its 24-hour pattern
- The red flag questions you asked, and the answers
- Home layout, work, and activity demands
- The patient’s own goals
Avoid: Writing “red flags negative” with no detail. Record what you asked, especially when the patient came by direct access.
Systems review
A quick screen of the cardiovascular and pulmonary, integumentary, musculoskeletal, and neuromuscular systems, plus communication and cognition, to catch problems outside the referral.
- Resting heart rate, blood pressure, and SpO2
- Skin and incision checks
- Gross strength, range, and symmetry
- Gross balance, gait, and transfers
- How the patient learns best
Avoid: Skipping it because the referral names one joint. The screen is where you find what the referral missed.
Tests and measures
The detailed exam, chosen from the history, using measures you will repeat to show change.
- ROM in degrees and strength grades, on both sides
- Special tests, with the result
- A neurological screen when symptoms point to one
- Balance and gait tests with scores
- One validated outcome measure as a baseline
Avoid: Testing everything. Pick measures tied to the problem and the goals, so the progress report can compare like with like.
Assessment
Your clinical reasoning: the physical therapy diagnosis, how the impairments explain the activity limits, and what helps or hinders recovery.
- The physical therapy diagnosis and the findings behind it
- Impairments linked to activity limitations
- Participation restrictions at home, work, or sport
- Health, psychosocial, and support factors
Avoid: A list of impairments with no link to function. Say how, for example, weak hip abductors lead to the fall risk.
Goals
Short-term and long-term goals the patient agrees with, each measurable and with a time frame.
- A functional outcome, not only an impairment
- A target number, distance, or assist level
- A time frame in weeks
- A baseline in tests and measures to compare against
Avoid: “Improve strength” or “decrease pain” with no measure and no time frame.
Plan of care
How you will reach the goals: frequency, duration, interventions, the home program, and where care goes after discharge.
- Visits per week and number of weeks
- The interventions you plan to use
- The home exercise program issued today
- The patient’s agreement, and who receives the report
Avoid: A plan that doesn’t match the goals. Every goal should have an intervention behind it.
Common mistakes, and how to avoid them.
Goals that only measure impairments
“Knee flexion to 120°” is a step, not the point. Pair impairment goals with the activity they serve, such as stairs or getting into a car.
No baseline behind the goals
Every goal needs a starting value in tests and measures. Without one, the progress report has nothing to compare.
No prior level of function
Without it, you can’t judge what “back to normal” means for this patient or set realistic long-term goals.
A thin red flag screen
Record the questions you asked and the answers, and what you did when something was positive. It matters most with direct access.
No frequency or duration
State visits per week and number of weeks. The next therapist and the payer both need it.
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Frequently asked questions.
What should a physical therapy evaluation include?
The referral and history, prior level of function, a systems review, tests and measures with a baseline outcome measure, your assessment and prognosis, measurable goals, and the plan of care with frequency and duration.
How do you write short-term and long-term goals in physical therapy?
Make each one functional, measurable, and time-bound: what the patient will do, how well, and by when. For example, “Climb 12 stairs with one rail, without help, in 4 weeks.” Short-term goals are steps toward the long-term ones.
What is the difference between a PT evaluation and a re-evaluation?
The evaluation starts an episode of care and sets the baseline, goals, and plan. A re-evaluation re-measures against that baseline and revises the goals and plan, at set intervals or when the patient’s status changes.
Which outcome measure should I use in a PT evaluation?
A validated measure for the body region or condition, such as the LEFS for the lower limb, the Oswestry for low back pain, or the Berg Balance Scale for balance. Use the same one at re-assessment and discharge.
How do you write the prognosis in a PT evaluation?
Rate the potential to reach the goals as good, fair, or poor, and give the reasons: the condition, time since onset, health, motivation, and support at home.
Is this physical therapy evaluation template free?
Yes. Copy it, or download it as a Word or text file. No account needed.
More physical therapy templates, and guides.
Physical therapy SOAP note template
Follow-up visit note with pain, ROM, MMT, special tests, timed interventions, and the home program.
Physical therapy daily note template
Per-visit treatment log: each intervention with parameters and minutes, the response, and next steps.
Physical therapy progress report template
Re-assessment with measures beside baseline, goal status, updated goals, and the case to continue.
Physical therapy discharge summary template
End-of-care summary with initial and final measures, goals met, the home program, and follow-up.
PT note examples
Worked notes for evaluation, daily treatment, progress, and discharge.
Patient intake
Bring visit goals, previous records, and preferences into one intake note before the evaluation.
Clinical note examples
Worked notes across formats, with checks before you sign.
Vero for physical therapy
Notes, documents, and follow-up in one workspace.
Common ICD-10 codes
The codes used most often in physical therapy.
Your template. Filled in from the visit.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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