Phone: ( - ) - Fax: ( - ) - : (Company Name) Outpatient Physical Therapy Evaluation

[COMPANY NAME]
Outpatient Physical Therapy Evaluation

Phone: (___)_________  Fax: (___)_________
Patient Name: Physician Name:
Diagnosis: Date of Evaluation:
Medications/Allergies/Precautions: Date of Onset:
Past Medical History
Subjective:
Physical Assessment
Speech:_____________________Vision:________________________Hearing:_______________________Cognition:_______________________________
Nutritional Screening: Appearance: Well-Nourished  YES  NO Well-Hydrated  YES  NO

Recent weight: Loss Gain Amount ___________________
Special Diet: ____________________________________________
Vitals:___________________________________________________________________________________________________________________________
Pain:____________________________________________________________________________________________________________________________
Posture/Body Mechanics:___________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
Gait:_____________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
Palpation:________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
Skin/Edema:______________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
Sensation:________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
Neurological Exam:________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
Special Tests:_____________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
PT Eval Page 2
ROM:____________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
Strength MMT):____________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
Initial Treatment:__________________________________________________________________________________________________________________
Assessment:________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
Rehab Potential: _______ Excellent _______Good _______Fair Barriers to Learning:________________________________________
Short-Term Goals:___________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Long-Term Goals:___________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Plan of Treatment:
____Manual Therapy ____Therapeutic Exercise ____Balance Training
____Neuromuscular Re-education ____Stretching ____Lumbopelvic Strengthening
____ADL Training ____Pt./Family Education ____Traction Lumbar/Cervical
____Gait Training ____Soft Tissue Mobilization ____Functional Activity
____Prosthetic Training ____Home Exercise Program ____Modalities as Indicated
____Will update and/or modify goals/P.O.C. as needed
Patient understands diagnosis/prognosis and consents to treatment plan and goals: ___Yes ___No
Frequency: ____________________ Duration: ____________________
I certify that I have examined the patient and physical therapy is necessary. The patient is under my care and the plan will be
reviewed every 30 days or more often if the patient’s conditions required.
____________ _________________________ ___________ _________________________

Date Therapist’s signature Date Physician’s signature
Revised: _________

Phone: ( - ) - Fax: ( - ) - : (Company Name) Outpatient Physical Therapy Evaluation

Uploaded by

Copyright:

Available Formats

Phone: ( - ) - Fax: ( - ) - : (Company Name) Outpatient Physical Therapy Evaluation

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Phone: ( - ) - Fax: ( - ) - : (Company Name) Outpatient Physical Therapy Evaluation

Uploaded by

Copyright:

Available Formats

[COMPANY NAME]

Outpatient Physical Therapy Evaluation

Patient Name: Physician Name:

Diagnosis: Date of Evaluation:

Medications/Allergies/Precautions: Date of Onset:

Past Medical History

Nutritional Screening: Appearance: Well-Nourished  YES  NO Well-Hydrated  YES  NO

Rehab Potential: ___ Excellent _Good _Fair Barriers to Learning:____________________________________

_______ _ _____________________

You might also like