Physical Therapy Initial Evaluation Form

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Patient#_______________ Provider_______
PHYSICAL THERAPY INITIAL EVALUATION FORM
PATIENT INFORMATION
DATE_____________________
NAME_______________________________________________
OCCUPATION______________________________________________
(LAST)
(FIRST)
BIRTHDATE_______________________
AGE______
HEIGHT____________
WEIGHT________lbs
HOME/CELL PHONE___________________________________
EMPLOYER________________________________________________
CURRENTLY EMPLOYED?
YES
NO
MODIFIED
REHAB INFORMATION
1. CHIEF COMPLAINT/AILMENT/INJURY_____________________________________________________________________________
2. DATE OF INJURY__________________________ DATE OF SURGERY_______________________
3. BRIEFLY DESCRIBE HOW YOU WERE INJURED
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
4. HAVE YOU RECEIVED THERAPY FOR THIS CONDITION?
YES
NO
WHEN?_______________________
HOW MANY VISITS?____________
5. HAS YOUR CONDITION BEEN GETTING:
WORSE
SAME
BETTER
6. ARE YOUR SYMPTOMS:
CONSTANT
OR
INTERMITTENT
7. MARK THE NUMBER THAT BEST CORRESPONDS TO YOUR PAIN:
AT BEST:
0
1
2
3
4
5
6
7
8
9
10 (EXCRUCIATING PAIN)
AT WORST:
0
1
2
3
4
5
6
7
8
9
10 (EXCRUCIATING PAIN)
8. WHAT DECREASES/MAKES YOUR CONDITION BETTER? (MARK ALL THAT APPLY)
BENDING
MOVEMENT
REST
BETTER IN AM
SITTING
STANDING
HEAT
BETTER AS DAY PROGRESSES
RISING
WALKING
ICE
BETTER IN PM
CHANGING POSITIONS
LYING
MEDICATION
N/A CAST JUST REMOVED
9. WHAT INCREASES/MAKES YOUR CONDITION WORSE? (MARK ALL THAT APPLY)
BENDING
MOVEMENT
REST
SNEEZE
SITTING
STANDING
STAIRS
DEEP BREATH
RISING
WALKING
COUGH
MEDICATION
PROLONGED POSITIONING
LYING
WORSE IN AM
WORSE IN PM
WORSE AS DAY PROGRESSES
N/A CAST JUST REMOVED
10. PREVIOUS MEDICAL INTERVENTION (MARK ALL THAT APPLY)
X-RAY MRI
CATSCAN
INJECTIONS
OTHER______________________________________________________

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