DOCUMENTATION TEMPLATE FOR PHYSICAL THERAPIST

Outpatient History
PATIENT/CLIENT MANAGEMENT Today’s Date: ______________
Outpatient Form 1, Page 1 Patient ID#:

1 Name: LIVING ENVIRONMENT

16 Does your home have: 17 Do you use:
a Last a ■ Stairs, no railing a ■ Cane
b ■ Stairs, railing b ■ Walker or rollator
c ■ Ramps c ■ Manual wheelchair
b First c MI d Jr/Sr
d ■ Elevator d ■ Motorized wheelchair
e ■ Uneven terrain e ■ Glasses, hearing aids
2 Street Address: __________________________________________ f ■ Assistive devices (eg, f ■ Other: _____________
bathroom): __________ ___________________
g ■ Any obstacles: ___________________
City State Zip ________________________

Month Day Year

18 Where do you live:
a ■ Private home
3 Date of Birth: ■ ■ ■ ■ ■■■■ b ■ Private apartment
c ■ Rented room
4 Sex: a ■ Male b ■ Female
d ■ Board and care / assisted living / group home
e ■ Homeless (with or without shelter)
5 Are you: a ■ Right-handed b ■ Left-handed
f ■ Long-term care facility (nursing home)
g ■ Hospice
6 Type of Insurance: a ■ Insurer ______________________________
h ■ Other: ____________________________________________
b ■ Workers’ Comp c ■ Medicare d ■ Self-pay e ■ Other
_________________________________________________
7 Race: 8 Ethnicity: 9 Language: 19 GENERAL HEALTH STATUS
a ■ American Indian a ■ Hispanic or a ■ English a Please rate your health:
or Alaska Native Latino understood (1) ■ Excellent (2) ■ Good (3) ■ Fair (4) ■ Poor
b ■ Asian b ■ Not Hispanic b ■ Interpreter
b Have you had any major life changes during past year? (eg, new
c ■ Black or African or Latino needed
baby, job change, death of a family member) (1) ■ Yes (2) ■ No
American c ■ Language you
d ■ Hispanic or speak most
Latino often: 20 SOCIAL/HEALTH HABITS
e ■ Native Hawaiian or ____________ a Smoking
Other Pacific Islander (1) Currently smoke tobacco? (a) ■ Yes 1. ■ Cigarettes:
f ■ White # of packs per day __
2. ■ Cigars/Pipes:
10 Education: # per day __
a Highest grade completed (Circle one): 1 2 3 4 5 6 7 8 9 10 11 12 (b) ■ No
b ■ Some college / technical school
c ■ College graduate
d ■ Graduate school / advanced degree
(2) Smoked in past? (a) ■ Yes Year quit: ■■■■ (b) ■ No

b Alcohol
SOCIAL HISTORY (1) How many days per week do you drink beer, wine, or other
11 Cultural/Religious: Any customs or religious beliefs or wishes that alcoholic beverages, on average? ___
might affect care? (2) If one beer, one glass of wine, or one cocktail equals one
_________________________________________________________ drink, how many drinks do you have on an average day? ___
12 With whom do you live: c Exercise
a ■ Alone Do you exercise beyond normal daily activities and chores?
b ■ Spouse only (a) ■ Yes Describe the exercise: ______________________
c ■ Spouse and other(s) 1. On average, how many days per week
d ■ Child (not spouse) do you exercise or do physical activity? _______
e ■ Other relative(s) (not spouse or children) 2. For how many minutes, on an average day? ____
f ■ Group setting (b) ■ No
g ■ Personal care attendant
h ■ Other:
21 FAMILY HISTORY (Indicate whether mother, father, brother/sister,
aunt/uncle, or grandmother/grandfather, and age of onset if known)
13 Have you completed an advance directive? a ■ Yes b ■ No
a Heart disease: __________________________________________
b Hypertension:__________________________________________
14 Who referred you to the physical therapist?
c Stroke: ________________________________________________
________________________________________________________ d Diabetes: ______________________________________________
e Cancer: _______________________________________________
15 Employment/Work (Job/School/Play)
a ■ Working full-time c ■ Working full-time f Psychological:__________________________________________
outside of home from home g Arthritis: ______________________________________________
b ■ Working part-time d ■ Working part-time h Osteoporosis:__________________________________________
outside of home from home
i Other: ________________________________________________
e ■ Homemaker f ■ Student g ■ Retired h ■ Unemployed

i Occupation: ___________________________________ © American Physical Therapy Association 1999; revised September 2000, January 2002, June 2003
 DOCUMENTATION TEMPLATE FOR PHYSICAL THERAPIST PATIENT/CLIENT MANAGEMENT
22 MEDICAL/SURGICAL HISTORY
a Please check if you have ever had:
(1) ■ Arthritis
(2) ■ Broken bones/
fractures
(3) ■ Osteoporosis
(4) ■ Blood disorders
(5) ■ Circulation/vascular
problems
(6) ■ Heart problems
(7) ■ High blood
pressure
(8) ■ Lung problems
(9) ■ Stroke
(10) ■ Diabetes/
high blood sugar
(11) ■ Low blood sugar/
Outpatient Form, Page 2
23 Current Condition(s)/Chief Complaint(s) (continued)
e How are you taking care of the problem(s) now? ____________
(13) ■ Multiple sclerosis ______________________________________________________
(14) ■ Muscular dystrophy f What makes the problem(s) better? ________________________
(15) ■ Parkinson disease ______________________________________________________
(16) ■ Seizures/epilepsy g What makes the problem(s) worse? ______________________
(17) ■ Allergies ______________________________________________________
(18) ■ Developmental or growth ______________________________________________________
problems h What are your goals for physical therapy? __________________
(19) ■ Thyroid problems ______________________________________________________
(20) ■ Cancer i Are you seeing anyone else for the problem(s)? (Check all that apply)
(21) ■ Infectious disease
(1) ■ Acupuncturist (10) ■ Occupational therapist
(eg, tuberculosis, hepatitis)
(22) ■ Kidney problems
(2) ■ Cardiologist (11) ■ Orthopedist
(23) ■ Repeated infections
(3) ■ Chiropractor (12) ■ Osteopath
(24) ■ Ulcers/stomach problems
(4) ■ Dentist (13) ■ Pediatrician
(25) ■ Skin diseases
■ Family practitioner (14) ■ Podiatrist
(5)

(26) ■ Depression
(6) ■ Internist (15) ■ Primary care physician
hypoglycemia
(27) ■ Other:_________________
■ Massage therapist (16) ■ Rheumatologist
(12) ■ Head injury
(7)
(8) ■ Neurologist Other: ____________________
b Within the past year, have you had any of the following (9) ■ Obstetrician/gynecologist
symptoms? (Check all that apply)
(1) ■ Chest pain (13) ■ Difficulty sleeping 24 FUNCTIONAL STATUS/ACTIVITY LEVEL (Check all that apply)
(2) ■ Heart palpitations (14) ■ Loss of appetite a ■ Difficulty with locomotion/movement:
(3) ■ Cough (15) ■ Nausea/vomiting (1) ■ Bed mobility
(4) ■ Hoarseness (16) ■ Difficulty swallowing (2) ■ Transfers (such as moving from bed to chair, from
(5) ■ Shortness of breath (17) ■ Bowel problems bed to commode)
(6) ■ Dizziness or blackouts (18) ■ Weight loss/gain (3) ■ Gait (walking)
(7) ■ Coordination problems (19) ■ Urinary problems (a) ■ On level (c) ■ On ramps
(8) ■ Weakness in arms or legs (20) ■ Fever/chills/sweats (b) ■ On stairs (d) ■ On uneven terrain
(9) ■ Loss of balance (21) ■ Headaches b ■ Difficulty with self-care (such as bathing, dressing, eating,
(10) ■ Difficulty walking (22) ■ Hearing problems toileting)
(11) ■ Joint pain or swelling (23) ■ Vision problems c ■ Difficulty with home management (such as household
(12) ■ Pain at night (24) ■ Other:________________ chores, shopping, driving/transportation, care of dependents)
d ■ Difficulty with community and work activities/integration
c Have you ever had surgery? (1) ■ Yes (2) ■ No (1) ■ Work/school
If yes, please describe, and include dates: (2) ■ Recreation or play activity
Month Year
25 MEDICATIONS
_________________________ ■■ ■■■■ a Do you take any prescription medications? (1) ■ Yes (2) ■ No
_________________________ ■■ ■■■■ If yes, please list: ______________________________________
_________________________ ■■ ■■■■ ______________________________________________________
b Do you take any nonprescription medications?
For men only: d Have you been diagnosed with prostate disease? (Check all that apply)
(1) ■ Yes (2) ■ No
(1) ■ Advil/Aleve (6) ■ Decongestants
For women only: Complicated pregnancies
h
(2) ■ Antacids (7) ■ Herbal supplements
Have you been diagnosed with: or deliveries? (3) ■ Ibuprofen/ ■ Tylenol
(1) ■ Yes (2) ■ No
(8)
e Pelvic inflammatory Naproxen (9) ■ Other: ________________
disease? i Pregnant, or think you
(4) ■ Antihistamines ________________________
(1) ■ Yes (2) ■ No might be pregnant? (5) ■ Aspirin ________________________
f Endometriosis? (1) ■ Yes (2) ■ No
(1) ■ Yes (2) ■ No j Other gynecological or c Have you taken any medications previously for the
g Trouble with your period? obstetrical difficulties? condition for which you are seeing the physical therapist?
(1) ■ Yes (2) ■ No (1) ■ Yes (2) ■ No
(1) ■ Yes (2) ■ No
If yes, please list:
If yes, please describe: ____________________________________
_______________________ 26 OTHER CLINICAL TESTS Within the past year, have you had any
23 CURRENT CONDITION(S)/CHIEF COMPLAINT(S) of the following tests? (Check all that apply)
a Describe the problem(s) for which you seek physical therapy: a ■ Angiogram m ■ Mammogram
______________________________________________________ b ■ Arthroscopy n ■ MRI
______________________________________________________ c ■ Biopsy o ■ Myelogram
Month Year d ■ Blood tests p ■ NCV (nerve conduction velocity)
b When did the problem(s) begin (date)? ■ ■ ■■■■ e ■ Bone scan q ■ Pap smear
c What happened?________________________________________ f ■ Bronchoscopy r ■ Pulmonary function test
______________________________________________________ g ■ CT scan s ■ Spinal tap
d Have you ever had the problem(s) before? h ■ Doppler ultrasound t ■ Stool tests
(1) ■ Yes i ■ Echocardiogram u ■ Stress test (eg, treadmill, bicycle)
j ■ EEG (electroencephalogram) v ■ Urine tests
(a) What did you do for the problem(s)? ____________
k ■ EKG (electrocardiogram) w ■ X-rays
_____________________________________________
l ■ EMG (electromyogram) x ■ Other:________________
(b) Did the problem(s) get better?
1. ■ Yes 2. ■ No
(c) About how long did the problem(s) last? __________
(2) ■ No
© American Physical Therapy Association 1999; revised September 2000, January 2002, June 2003
 DOCUMENTATION TEMPLATE FOR

Systems Review
PHYSICAL THERAPIST PATIENT/CLIENT MANAGEMENT
Systems Review

Not Not
Impaired Impaired Impaired Impaired

CARDIOVASCULAR/PULMONARY SYSTEM ■ ■ MUSCULOSKELETAL SYSTEM

Blood pressure: ________________________ Gross Range of Motion ■ ■
Edema: ________________________________ Gross Strength ■ ■
Heart rate: ____________________________ Gross Symmetry ■ ■
Respiratory rate: ________________________ Standing: ____________________________
Sitting: ______________________________
Activity specific:______________________

Other: ________________________________
INTEGUMENTARY SYSTEM ■ ■
Integrity
Height ______________________
Pliability (texture):____________________
Presence of scar formation: ____________
Skin color: __________________________ Weight ______________________
Skin integrity: ________________________

NEUROMUSCULAR SYSTEM
Gross Coordinated Movements
Balance ■ ■
Gait ■ ■
Locomotion ■ ■
Transfers ■ ■
Transitions ■ ■
Motor function (motor control, motor learning) ■ ■
COMMUNICATION, AFFECT, COGNITION,
LEARNING STYLE
Communication (eg, age-appropriate) ■ ■
Orientation x 3 (person/place/time) ■ ■
Emotional/behavioral responses ■ ■
Learning barriers: Education needs:
■ None ■ Disease process
■ Vision ■ Safety
■ Hearing ■ Use of devices/equipment
■ Unable to read ■ Activities of daily living
■ Unable to understand what is read ■ Exercise program
■ Language/needs interpreter ■ Other: ______________________________________________
■ Other: ____________________________________________

How does patient/client best learn? ■ Pictures ■ Reading ■ Listening ■ Demonstration ■ Other:

© American Physical Therapy Association 1999; revised September 2000, January 2002, June 2003
 DOCUMENTATION TEMPLATE FOR

Tests and Measures

PHYSICAL THERAPIST PATIENT/CLIENT MANAGEMENT
Tests and Measures

KEY TO TESTS AND MEASURES:

1 Aerobic Capacity/Endurance 14 Neuromotor Development and Sensory Integration

2 Anthropometric Characteristics 15 Orthotic, Protective, and Supportive Devices
3 Arousal,Attention, and Cognition 16 Pain
4 Assistive and Adaptive Devices 17 Posture
5 Circulation (Arterial,Venous, Lymphatic) 18 Prosthetic Requirements
6 Cranial and Peripheral Nerve Integrity 19 Range of Motion (Including Muscle Length)
7 Environmental, Home, and Work (Job/School/Play) Barriers 20 Reflex Integrity
8 Ergonomics and Body Mechanics 21 Self-Care and Home Management (Including Activities of Daily
9 Gait, Locomotion, and Balance Living and Instrumental Activities of Daily Living)
10 Integumentary Integrity 22 Sensory Integrity
11 Joint Integrity and Mobility 23 Ventilation and Respiration/Gas Exchange
12 Motor Function (Motor Control and Motor Learning) 24 Work (Job/School/Play), Community, and Leisure Integration or
13 Muscle Performance (Including Strength, Power, and Endurance) Reintegration (Including Instrumental Activities of Daily Living)

NOTES:
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© American Physical Therapy Association 1999; revised September 2000, January 2002, June 2003
 DOCUMENTATION TEMPLATE FOR
PHYSICAL THERAPIST PATIENT/CLIENT MANAGEMENT

Evaluation
Evaluation
PREFERRED PHYSICAL THERAPIST PRACTICE PATTERNSSM
DIAGNOSIS:
Musculoskeletal Patterns Cardiovascular/Pulmonary Patterns
■ A: Primary Prevention/Risk Reduction for Skeletal ■ A: Primary Prevention/Risk Reduction for
Demineralization Cardiovascular/Pulmonary Disorders
■ B: Impaired Posture ■ B: Impaired Aerobic Capacity/Endurance Associated With
■ C: Impaired Muscle Performance Deconditioning
■ D: Impaired Joint Mobility, Motor Function, Muscle Performance, ■ C: Impaired Ventilation, Respiration/Gas Exchange, and Aerobic
and Range of Motion Associated With Connective Tissue Capacity/Endurance Associated With Airway Clearance
Dysfunction Dysfunction
■ E: Impaired Joint Mobility, Motor Function, Muscle Performance, ■ D: Impaired Aerobic Capacity/Endurance Associated With
and Range of Motion Associated With Localized Inflammation Cardiovascular Pump Dysfunction or Failure
■ F: Impaired Joint Mobility, Motor Function, Muscle Performance, ■ E: Impaired Ventilation and Respiration/Gas Exchange
Range of Motion, and Reflex Integrity Associated With Spinal Associated With Ventilatory Pump Dysfunction or Failure
Disorders ■ F: Impaired Ventilation and Respiration/Gas Exchange
■ G: Impaired Joint Mobility, Muscle Performance, and Range of Associated With Respiratory Failure
Motion Associated With Fracture ■ G: Impaired Ventilation, Respiration/Gas Exchange, and
■ H: Impaired Joint Mobility, Motor Function, Muscle Performance, Aerobic Capacity/Endurance Associated With
and Range of Motion Associated With Joint Arthroplasty Respiratory Failure in the Neonate
■ I: Impaired Joint Mobility, Motor Function, Muscle Performance, ■ H: Impaired Circulation and Anthropometric Dimensions
and Range of Motion Associated With Bony or Soft Tissue Associated With Lymphatic System Disorders
Surgery
■ J: Impaired Motor Function, Muscle Performance, Range of Integumentary Patterns
Motion, Gait, Locomotion, and Balance Associated With ■ A: Primary Prevention/Risk Reduction for Integumentary
Amputation Disorders
■ B: Impaired Integumentary Integrity Associated With Superficial
Neuromuscular Patterns Skin Involvement
■ A: Primary Prevention/Risk Reduction for Loss of ■ C: Impaired Integumentary Integrity Associated With Partial-
Balance and Falling Thickness Skin Involvement and Scar Formation
■ B: Impaired Neuromotor Development ■ D: Impaired Integumentary Integrity Associated With Full-
■ C: Impaired Motor Function and Sensory Integrity Associated Thickness Skin Involvement and Scar Formation
With Nonprogressive Disorders of the Central Nervous ■ E: Impaired Integumentary Integrity Associated With Skin
System—Congenital Origin or Acquired in Infancy or Involvement Extending Into Fascia, Muscle, or Bone and Scar
Childhood Formation
■ D: Impaired Motor Function and Sensory Integrity Associated
With Nonprogressive Disorders of the Central Nervous
System—Acquired in Adolescence or Adulthood
■ E: Impaired Motor Function and Sensory Integrity Associated
With Progressive Disorders of the Central Nervous System
■ F: Impaired Peripheral Nerve Integrity and Muscle Performance
Associated With Peripheral Nerve Injury
■ G: Impaired Motor Function and Sensory Integrity Associated
With Acute or Chronic Polyneuropathies
■ H: Impaired Motor Function, Peripheral Nerve Integrity, and
Sensory Integrity Associated With Nonprogressive Disorders
of the Spinal Cord
■ I: Impaired Arousal, Range of Motion, and Motor Control
Associated With Coma, Near Coma, or Vegetative State
PROGNOSIS: ____________________________________________________________________________________________________________
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© American Physical Therapy Association 1999; revised September 2000, January 2002, June 2003
 DOCUMENTATION TEMPLATE FOR
PHYSICAL THERAPIST PATIENT/CLIENT MANAGEMENT

Plan of Care
Plan of Care

Anticipated Goals: ________________________________________________________________________________________________________

________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________

Expected Outcomes: ______________________________________________________________________________________________________

________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________

Interventions: ______________________________________________________________________________ Frequency of Visits/Duration

of Episode of Care:
__________________________________________________________________________________________ ________________________
__________________________________________________________________________________________ ________________________
__________________________________________________________________________________________ ________________________
__________________________________________________________________________________________

Education (including safety, exercise, and disease information): __________________________________________________________________

________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________

Who was educated? ■ Patient/client ■ Family (name and relationship): ________________________________________________________

How did patient/family demonstrate learning:
■ Patient/client verbalized understanding
■ Family/significant other verbalized understanding
■ Patient/client demonstrated correctly
■ Demonstration was unsuccessful (describe): ____________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________

Discharge Plan: __________________________________________________________________________________________________________

________________________________________________________________________________________________________________________
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© American Physical Therapy Association 1999; revised September 2000, January 2002, June 2003