INITIAL EVALUATION

Name: Type of PT: (Room number if IP)

Address: Admitting Physician:
Date of Birth: Attending Physician:
Age: Referring Physician:
Civil Status: Rehabilitation Physician:
Nationality: Medical Diagnosis:
Gender: Reason for Referral:
Religion: Date of Initial Evaluation:
Occupation: Informant/s and Reliability:
Handedness:

/S/:
C/C:

HPI:

Medications:
Name Dosage Frequency Drug Indication Adverse
Classificatio Effect
n
Ancillary Service: (X-ray/CT/MRI/etc)
Procedure Date Impression Hospital

Laboratory Results:
Blood Works Date Result Normal Value

Past Medical History: (Medical Consultation/Hospital Admission)

Consultation/ Date Significance Outcome
Admission

Personal and Social History:

Personal and Social Health Habits:

Prior Level of Function:

Functional History:
Family History:
Disease Paternal Maternal Patient
HTN
DM
Asthma
Arthritic
Conditions
Ca
Others:
Findings:
Significance:

Home Situation/Living Condition:

Type of House:
Stairs:
Type of Flooring
Pt.’s Room-Living Room
Pt.’s Room-Comfort Room
Pt.’s Room-Dining Room
Pt.’s Room-Kitchen
Pt.’s Room-Gate

Pt’s Goal:

Work/Employment Status: