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Physical Therapy Evaluation Form

The Physical Therapy Evaluation form can be used when a patient checks in into a physical therapy facility to indicate the type of treatment he will need.

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PHYSICAL THERAPY INITIAL EVALUATION FORM	
PATIENT INFORMATION	                  DATE_____________________	
NAME_______________________________________________       OCCUPATION______________________________________________
   (LAST)                 (FIRST)
BIRTHDATE_______________________     AGE______        HEIGHT____________      WEIGHT________lbs 
HOME/CELL PHONE___________________________________      EMPLOYER________________________________________________
CURRENTLY EMPLOYED?         YES         NO         MODIFIED
REHAB INFORMATION
  1. CHIEF COMPLAINT/AILMENT/INJURY_______________________________________________________________________\
______
  2. DATE OF INJURY__________________________    DATE OF SURGERY_______________________
  3. BRIEFLY DESCRIBE HOW YOU WERE INJURED	
    ____________________________________________________________________\
__________________________________________
    ____________________________________________________________________\
__________________________________________	
  4. HAVE YOU RECEIVED THERAPY FOR THIS CONDITION?         YES         NO         WHEN?_______________________
      HOW MANY VISITS?____________
  5. HAS YOUR CONDITION BEEN GETTING:     WORSE SAME   BETTER
  6. ARE YOUR SYMPTOMS:         CONSTANT      OR          INTERMITTENT
  7. MARK THE NUMBER THAT BEST CORRESPONDS TO YOUR PAIN:
      AT BEST:        0      1      2      3      4      5      6      7      8      9       10 (EXCRUCIATING PAIN)
      AT WORST:          0       1      2      3      4      5      6      7      8      9       10 (EXCRUCIATING PAIN)
  8. WHAT DECREASES/MAKES YOUR CONDITION BETTER? (MARK ALL THAT APPLY)
 BENDING          MOVEMENT                        REST            BETTER IN AM
 SITTING          STANDING            HEAT            BETTER AS DAY PROGRESSES
 RISING                       WALKING             ICE           BETTER IN PM
 CHANGING POSITIONS                    LYING                        MEDICATION           N/A  CAST JUST REMOVED
  9. WHAT INCREASES/MAKES YOUR CONDITION WORSE? (MARK ALL THAT APPLY)
 BENDING                      MOVEMENT     REST                SNEEZE
 SITTING                      STANDING      STAIRS                            DEEP BREATH
 RISING                                   WALKING      COUGH                            MEDICATION
 PROLONGED POSITIONING                  LYING                                            WORSE IN AM               WORSE IN PM
              WORSE AS DAY PROGRESSES                  N/A  CAST JUST REMOVED
 
  10. PREVIOUS MEDICAL INTERVENTION (MARK ALL THAT APPLY)
 X-RAY MRI      CATSCAN      INJECTIONS           OTHER______________________________________________________	
Patient#_______________ Provider_______

11. WHAT ARE YOUR GOALS TO BE ACHIEVED BY THE END OF THERAPY?
________________________________________________________________________\
________________________________________
________________________________________________________________________\
________________________________________	
DRAW IN AREAS OF PAIN ON BODY DIAGRAMS USING APPROPRIATE SYMBOLS. If you are completing this form on the 
computer, print form after completion and mark the diagram with a pen.	
Patient#_______________ Provider_______	
SEVERE PAIN	                      	*******	
MODERATE PAIN 	           00000000	
DULL ACHE	              	∩∩∩∩∩∩	
RADIATING PAIN 	          	↑↓↑↓↑↓↑↓	
NUMBNESS/TINGLING 	         XXXXXX	
MEDICAL INFORMATION	 (MARK ALL THAT APPLY) **THIS INFORMATION IS CONFIDENTIAL AND REMAINS PART OF 	
YOUR CHART
  DIFFICULTY SWALLOWING    MOTION SICKNESS     STROKE
 ARTHRITIS        FEVER/CHILLS/SWEATS   OSTEOPOROSIS
 HIGH BLOOD PRESSURE    UNEXPLAINED WEIGHT LOSS               ANEMIA
 HEART TROUBLE      BLOOD CLOTS                   BLEEDING PROBLEMS
 PACEMAKER        SHORTNESS OF BREATH   HIV/HEPATITIS
 EPILEPSY/SEIZURES      HISTORY OF SMOKING                HISTORY OF ALCOHOL ABUSE 
 HISTORY OF DRUG ABUSE    DIABETES       DEPRESSION/ANXIETY
 MYOFASCIAL PAIN      FIBROMYALGIA      PREGNANCY
 CANCER
PREVIOUS SURGERIES:_____________________________________________________\
________________________________________
OTHER:__________________________________________________________________\
_________________________________________
MEDICATIONS:
________________________________________________________________________\
__________________________________________
________________________________________________________________________\
__________________________________________
ALLERGIES:______________________________________________________________\
_________________________________________
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