PHYSICAL THERAPY INITIAL EVALUATION

_____/_____/_____
Name: DOB: Age/Sex: Civial Status:
Address: Contact #:
Diagnosis: Physician's Name:

SUBJECTIVE FINDINGS
CHIEF COMPLAINT:
PAIN SCALE: History of Present Illness PMHx
Frequency:
Type of Pain:
Location:
Onset:
Aggraviated by:
Relieving by:
Family Hx Medication Ancillary Procedure

Objective Findings
Vital Signs: Before After OCCULAR INSPECTION PALPATION

BP:
PR:
RR:
TEMP:

ROM MEASUREMENT MMT

Motion Active Passive Normal Difference Endfeel MUSCLE GRADE

SPECIAL TEST LIMB GIRTH MEASUREMENT LEG LENGTH MEASUREMENT RGR

TEST Result CM CIRCUMFERENCE REFERENCE CM
UMBLICAL TO
LATERAL MALLEOLUS
MEDIAL MALLEOLUS SENSORY TEST
MUSCLE BULK MEASUREMENT SIG:
MUSLCE TESTED CM ASIS TO
FROM: LATERAL MALLEOLUS
TO: MEDIAL MALLEOLUS
SIG: SIG:
 BALANCE AND TOLERANCE TONE ASSESSMENT Postural Analysis
BALANCE AREA SPASTIC NORMAL FLACCID
NORMAL = ASSUME, MAINTAIN, CHALLENGE UE
GOOD = ASSUME/MAINTAIN/ CANT CHALLENGE LE
FAIR = CAN ASSUME CANNOT MAINTAIN TRUNK
POOR = CANNOT ASSUME/MAINTAIN
GRADE OF SPASTICITY:
TOLERANCE 0 = NO Increase in muscle tone
Normal = > 1hour 1 = Slight Inc.;catch;resist at end of range
Good = 30mins to 1 hour 1+ = Slight Inc.; catch; resist half of range
Fair = 15mins to 1 hour 2 = marked Inc. through most of ROM
Fair + = 5mins to 15mins 3 = Considerable Inc. passive movt diff.
Poor = 1mins to 5mins 4 = Rigidity
BAL TOL 5 = unable to test
Sitting sig:
Standing
GAIT ANALYSIS PROBLEM LIST SHORT TERM GOAL

Type of Gait:
TREATMENT PLAN

PT-IN-CHARGE
 PHYSICAL THERAPY NOTES
PATIENT'S NAME: AGE/GENDER: CIVIL STATUS:
ADDRESS: DOB: CONTACT #:
DIAGNOSIS:
DATE DATE
DATE DATE
 PROGRESS NOTES
NAME: AGE/SEX: CIVIL STATUS:
DIAGNOSIS: PHYSICIAN:
PROBLEM LIST
PROBLEM LIST