Hospital Physical Therapy Department

Initial Evaluation

Name: _____________ ______ Age: _____ Gender: Male/Female Marital status: Single □ Married □
Occupation: ____________________ Consultations: ___________________
Admitted Date: ______________ Evaluation Date: _______________ _ Diagnosis: _________________
Diagnosis Impairment Functional Limitation Disability
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Clinical Impression/Prognosis:

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Goals:
STGs LTGs

Treatment Plan:

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“SUPERVISED BY”

Dr. M ASIM ARIF

Assistant Prof./IN Charge Physical Therapy Department
ULTH

Dr. HIRA SHAFIQ Dr. Saweera Saleem

Physical Therapist/Senior Lecturer Physical Therapist/ Lecturer

Dr. Asma Akram Dr. Mehwish Azam

Physical Therapist/ Lecturer Physical Therapist/ Lecturer