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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