PHYSICAL THERAPY EVALUATION

(Lower)

PHYSICIAN:
DATE OF SERVICE:
MEDICAL DIAGNOSIS:
DATE OF SURGERY:
PHYSICAL THERAPY DIAGNOSIS:
RETURN TO PHYSICIAN:
AUTHORIZATION:

SUBJECTIVE:

PAST MEDICAL/ SURGICAL HISTORY:

PRIOR LEVEL OF FUNCTION:

SOCIAL HISTORY:
Lives in
With
Storey/ Level
STE
ADLs
DME
Ambulation in house
Ambulation in community

PAIN ASSESSMENT
Location

Intensity (NAS)
Radiation
Type
Aggravating Factors
Relieving factors

TREATMENT TO DATE:

Patient Goals:

OBJECTIVE:

Incision

Palpation
Posture
Integumentary

GAIT OBSERVATIONS:
Device

Assistance
Distance
Deviations
Stairs
Others

ROM & STRENGTH:

LE :

RIGHT ROM/STRENGTH LEFT

ROM STRENGT ACTION ROM STRENGTH
H
Hip Flexion (120°)
Hip Extension (30°)
Hip Abd (45°)
Hip Add (30°)
Hip IR (45°)
Hip ER (45°)
Knee Flexion (135°)
Knee Extension (0°)
Ankle DF (20°)
Ankle PF (50°)
Ankle Inversion (30-40°)
Ankle Eversion (15-20°)
Other:

Comments (Tone, Mvmt Patterns, Pain, Reflexes, End Feel):

SPECIAL TESTS:

Treatment Performed:

ASSESSMENT:

FUNCTIONAL LIMITATIONS:
SHORT TERM GOALS: TO BE ACHIEVED IN -- WEEKS
1. Pt will report compliance and independence with the initial HEP to help with the progression of therapy.

LONG TERM GOALS: TO BE ACHIEVED IN -- WEEKS

1. Pt will report compliance and independence with the final HEP to allow for carryover from therapy following
discharge.

PLAN OF CARE:
Pt would benefit from skilled therapy to address impairments and functional limitations so that she can achieve her
personal and therapy goals. As per physicians order ------- visits. Need of further therapy will be determined after
4 weeks/ 30 days. Physical therapy session to include but not limited to the following: therapeutic exercise,
functional activities, strengthening, gait training, HEP, orthotic/equipment needs, patient education and discharge
planning. Above goals and treatment plan have been discussed with patient/caregiver who verbalized
understanding and agreement.

REHAB POTENTIAL: Good for the goals set.

ADDITIONAL COMMENTS:

TIME START:
TIME END:
CHARGES:
CREDENTIALS: