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Initial Eval Form New

This physical therapy initial evaluation form collects information about a patient's medical history, current symptoms, and treatment goals. It documents details such as the patient's name, date of birth, contact information, occupation, current medical conditions, previous injuries and surgeries, medications, and symptoms. The patient rates their current and worst pain levels, and identifies factors that make their condition better or worse. Treatment history and goals are also noted, along with diagrams marking the location and type of any pain being experienced.

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Earll Justin N. Data
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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214 views2 pages

Initial Eval Form New

This physical therapy initial evaluation form collects information about a patient's medical history, current symptoms, and treatment goals. It documents details such as the patient's name, date of birth, contact information, occupation, current medical conditions, previous injuries and surgeries, medications, and symptoms. The patient rates their current and worst pain levels, and identifies factors that make their condition better or worse. Treatment history and goals are also noted, along with diagrams marking the location and type of any pain being experienced.

Uploaded by

Earll Justin N. Data
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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PHYSICAL THERAPY INITIAL EVALUATION FORM

PATIENT INFORMATION
DATE_______________
NAME___________________________________________ OCCUPATION _________________________
(LAST) (FIRST)
BIRTHDATE _______________ AGE _______ HEIGHT ________ WEIGHT _________lbs.
ADDRESS ____________________________________ PHONE NUMBER___________________________
____________________________________________ SSN _____________________________________
HOME/CELL PHONE ___________________________ EMAIL ___________________________________
CURRENTLY EMPLOYED? YES NO MODIFIED EMPLOYER____________________________
STUDENT YES NO

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
PACEMAKERS 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: ____________________________________________________________________________________
REFERRING MD ___________________________ DIAGNOSIS _____________________ SURGERY (Y) (N)
MEDICATIONS (PLEASE INCLUDE DOSAGES): _________________________________________________
_____________________________________________________________________________________
IS YOUR INJURY/PAIN DUE TO (CIRCLE ONE): SPORT/SURGERY/FALL/CAR ACCIDENT/WORK RELATED/
INJURY/ABUSE
WORKERS COMPENSTATION? YES NO NO FAULT (AUTO ACCIDENT)? YES NO

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 BETTER WORSE SAME
6. ARE YOUR SYMPTOMS CONSTANT OR INTERMITTENT
7. CIRCLE 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 POSITION LYING MDICATION 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

10. PREVIOUS MEDICAL INTERVENTION (MARK ALL THAT APPLY)


X-RAY/MRI CATSCAN INJECTIONS OTHER_________________________________

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.

SEVERE PAIN *****


MODERATE PAIN 00000
DULL ACHE !!!!!!!!
RADIATING PAIN ↓↑↓
NUMBNESS/TINGLING XXXXX

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