Physical therapists help to improve a patient's mobility, function, strength and overall quality of life. Evaluation forms are important tools for these professionals in order to properly assess the needs of their patients. To assist in the process, an accurate physical therapist evaluation form must be filled out prior to treatment so that both the therapist and patient can determine if progress is being made during the course of treatment. In this blog post we will provide you with pictures of a sample physical therapy evaluation form as well as descriptions on what each section involves so that you can have a better understanding on how it works and why it’s important in providing successful treatments!
| Question | Answer |
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| Form Name | Pictures Of A Physical Therapist Evaluation Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | shoulder evaluation physical therapy format, us dept of labor physical therapy forms pdf, physical therapy pediatric 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?
______________________________________________________________________________________________
Other Comments:
______________________________________________________________________________________________
2680 18TH STREET, SUITE 150 B DENVER, CO 80211