Physical Therapy Evaluation Form Sample
11. WHAT ARE YOUR GOALS TO BE ACHIEVED BY THE END OF THERAPY?
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
DRAW IN AREAS OF PAIN ON BODY DIAGRAMS USING APPROPRIATE SYMBOLS. If you are completing this form on the
computer, print form after completion and mark the diagram with a pen.
Patient#_______________ Provider_______
SEVERE PAIN *******
MODERATE PAIN 00000000
DULL ACHE ∩∩∩∩∩∩
RADIATING PAIN ↑↓↑↓↑↓↑↓
NUMBNESS/TINGLING XXXXXX
MEDICAL INFORMATION (MARK ALL THAT APPLY) **THIS INFORMATION IS CONFIDENTIAL AND REMAINS PART OF
YOUR CHART
DIFFICULTY SWALLOWING MOTION SICKNESS STROKE
ARTHRITIS FEVER/CHILLS/SWEATS OSTEOPOROSIS
HIGH BLOOD PRESSURE UNEXPLAINED WEIGHT LOSS ANEMIA
HEART TROUBLE BLOOD CLOTS BLEEDING PROBLEMS
PACEMAKER SHORTNESS OF BREATH HIV/HEPATITIS
EPILEPSY/SEIZURES HISTORY OF SMOKING HISTORY OF ALCOHOL ABUSE
HISTORY OF DRUG ABUSE DIABETES DEPRESSION/ANXIETY
MYOFASCIAL PAIN FIBROMYALGIA PREGNANCY
CANCER
PREVIOUS SURGERIES:_____________________________________________________________________________________________
OTHER:___________________________________________________________________________________________________________
MEDICATIONS:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
ALLERGIES:_______________________________________________________________________________________________________
Page 2/2
Free Download
Physical Therapy Evaluation Form Sample PDF
Favor this template? Just fancy it by voting!
(1 Votes)
5.0
Related Forms
