PHYSICAL 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]