PHYSICAL THERAPY INITIAL EVALUATION

PHYSICIAN:
DATE OF SERVICE:
MEDICAL DIAGNOSIS:
RETURN TO PHYSICIAN:
PHYSICAL THERAPY DIAGNOSIS:
Decreased endurance, ms weakness, difficulty in ambulation, decreased
functional mobility
DATE OF SURGERY:
LAST HOSPITALIZATION:
OP MEDICAL SCREEN :

SUBJECTIVE:
 How long can you walk before you have leg pain?;
 What other symptoms do you have when you walk?
 How long after you rest does the pain subside?
 Home oxygen therapy?

PRIOR LEVEL OF FUNCTION:

PATIENT’S GOAL: " to get better "

PAST MEDICAL / Surgical HISTORY:

MEDICATIONS:

SOCIAL HISTORY:
Lives in
With
Storey/ Level
STE
ADLs
Dressing , bathing, grooming,
cooking
DME
Ambulation in house
Ambulation in community
Recreational Activities

PAIN ASSESSMENT:
Location

Intensity
Radiation
Type
 Aggravating Factors
Relieving factors
Associated Pain

VITAL ASSESSMENT
BP

RPE on revised BORG

PP
Medications prior to session
Pedal Edema

TREATMENT TO DATE:

POSTURE: Obese, rounded shoulders

LOWER EXTREMITY ROM and STRENGTH:

ROM Strength

Comments :

COMMENTS:

UPPER EXTREMITY Muscle and strength Testing :

ROM Strength

Comments :

SPECIAL TESTS:
6 min walk test/ 2 min walk test
Submaximal Cycle Ergometer
DUKE ( DASI score)
Sit to stand
Step test
 Comments: SIX MINUTE WALK TEST

Resting Post- Exercise

HR bpm
BP
RR (breath/ min)
RPE
SaO2
Breathing Pattern

Minutes Total Distance in HR bpm SaO2 RPE

Meters
1
2
3
4
5
6
Total Distance
Rests: no./ Time

Symptoms
during test
Comments

Number of Laps: _____ (x 60 meters) + final partial lap: ______ meters =

Total Distance walked in 6 minutes: ______ meters

GAIT OBSERVATIONS:
Device

Assistance
Distance
Deviations
Others

ASSESSMENT: Pt presents with diagnosis of . Presents with poor endurance, ms

weakness, decreased tolerance to activities, chest tightness and pain. Pt would benefit
from skilled therapy to address impairments and functional limitations so that she can
achieve her personal and therapy goals. Pt will be seen for 2 times / week for 6 weeks.
Need fr further therapy will be determined after 6 weeks. Physical therapy session to
include but not limited to the following: therapeutic exercise, functional activities,
strengthening, endurance training, education, 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.

FUNCTIONAL LIMITATIONS:
weakness contributing to poor endurance
Difficulty in ambulation and poor balance

SHORT TERM GOALS: TO BE ACHIEVED IN 3 WEEKS

1. Pt will report compliance and independence with the initial HEP to help with the
progression of therapy.
2. Pt will be educated on benefits of exercise, relaxation techniques, weight control,
diabetes and smoking cessation.
3. Patient will exhibit
4. Patient will exhibit

LONG TERM GOALS: TO BE ACHIEVED IN 6 WEEKS

1. Pt will report compliance and independence with the final HEP to allow for carryover
from therapy following discharge.
2. Pt will demonstrate improve distance on.
3. Pt will demonstrate increase endurance and tolerance to activities with MET level 8-
9….
4. Pt will demonstrate increase strength

REHAB POTENTIAL: Fair

Treatment Today :
Patient Education:
Smoking YES

BP monitoring YES

Edema Monitoring and Management YES

Compliance to PT and HEP YES

attendance Policy YES

Cardiac Program and graded exercises YES

UE function and restriction YES

ADDITIONAL COMMENTS:

TIME BEGAN:
TIME END:
CHARGES: Initial Evaluation
NAME/CREDENTIALS: