The Pictures Of A Physical Therapist Evaluation form, utilized by LoHi Physical Therapy, is a comprehensive document designed to gather essential information from patients seeking therapy services. This form, accessible at both 2680 18th Street, Suite 150 B in Denver, Colorado, and through contact methods like phone (303-458-9660) and email (info@CatalystTherapies.com), serves as a preliminary self-assessment tool. It encourages patients to provide detailed accounts of their symptoms, their severity, and their impact on daily life. The form prompts patients to indicate the location and nature of their discomfort using descriptors such as severe, sharp, or aching, and to rate their symptoms on a scale from zero to ten. Furthermore, it probes into the onset of these symptoms, potential causes, aggravating and alleviating factors, and any disturbance to sleep patterns. Patients are also asked about their medical history concerning the condition, including physician consultations, diagnostic tests, and prior treatments. Additionally, it seeks information on medication use, occupational impacts, exercise routines, and recreational activities affected by the condition. Importantly, it asks the patient to outline their treatment goals and the time they are willing to commit to therapy. Through its comprehensive approach, the form not only assists therapists in tailoring treatment plans but also fosters an open line of communication between the therapist and patient right from the start.
| Question | Answer |
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| Form Name | Pictures Of A Physical Therapist Evaluation Form |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 39 |
| Avg. time to fill out | 8 min 22 sec |
| Other names | shoulder evaluation physical therapy format, therapy initial self evaluation, initial self evaluation form, pedcicatric phsyical threapy evaluation template |
LoHi Physical Therapy |
Ph |
Fax |
Occupational - Hand Therapy |
info@CatalystTherapies.com |
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@CatalystTherapies.com |
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INITIAL SELF EVALUATION FORM |
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Name____________________________________ |
Date ___________________ |
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Please tell us about yourself, so that we can serve you better. If you have difficulty answering any question, or if it doesn’t apply to you, just leave it blank. You will have ample opportunity to clarify or explain any of your answers
during your evaluation and treatment sessions.
Who referred you to us? _________________________________________________________________________
What is your reason for seeking therapy? ____________________________________________________________
Please mark or shade in any areas where you have been experiencing discomfort. You can label each area with one
or more descriptor from the following list: |
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Severe |
Sharp |
Burning |
Aching |
Moderate |
Dull |
Throbbing |
Stabbing |
Numbness/tingling |
Weakness |
Radiating (indicate direction with arrow) |
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List & rate each symptom you have been experiencing. Rate on a scale of
a. ____________________________________________________________ |
0 1 2 3 4 5 6 7 8 9 10 |
b. ____________________________________________________________ |
0 1 2 3 4 5 6 7 8 9 10 |
c. ____________________________________________________________ |
0 1 2 3 4 5 6 7 8 9 10 |
d. ____________________________________________________________ |
0 1 2 3 4 5 6 7 8 9 10 |
When did your symptoms begin? ___________________________________________________________________
What do you think causes your symptoms? ___________________________________________________________
2680 18TH STREET, SUITE 150 B DENVER, CO 80211
LoHi Physical Therapy |
Ph |
Fax |
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Occupational - Hand Therapy |
info@CatalystTherapies.com |
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@CatalystTherapies.com |
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What makes your symptoms worse? Sitting __ |
Standing __ Bending __ Lifting __ Walking __ Running __ |
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Other, describe: |
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What eases your symptoms? |
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Please describe the daily pattern of your symptoms. Type and severity of discomfort. First thing in the morning?
Later morning?
Late afternoon?
Evening?
Is your sleep pattern disturbed?
How many hours of sleep do you typically have per night?
Have you been seen by a physician for these symptoms? If so, what was the diagnosis?
Have you had any diagnostic tests done?
access to any reports or films, it would be helpful to bring them in.)
Have you had any previous treatment for this condition? (Previous Physical Therapy, chiropractic, massage, etc.) What were the results?
Are you presently taking any medications? Please list.
What is your occupation?
How much, if any, is your work affected by your condition?
What recreational or leisure activities do you enjoy?
Describe your types and amounts of routine exercise?
Are these affected by your condition?
Please describe your goals for your treatment?
How much time (per day or per week) are you willing to commit to improve your symptoms?
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Other Comments:
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2680 18TH STREET, SUITE 150 B DENVER, CO 80211