Physical therapy evaluation form

1. CodesNT
NA
I
S
SBA
= Not Tested
= Not Applicable
= Independent
= Supervised
= Stand By Assist
CGA
Min. A
Mod. A
Max. A
U
= Contact Guard Assist
= Minimal Assist
= Moderate Assist
= Maximum Assist
= Unable
WBAT
PWB
TTWB
NWB
= Weight Bear as tolerated
= Partial Weight Bearing
= Toe Touch Wt. Bearing
= Non-Weight Bearing
Equipment HW = Hemiwalker
CR = Crutches SW = Standard Walker
SPC = Single Point Cane FWW = Front Wheel Walker
NBQC= Narrow Base Quad Cane 4WW = Four Wheel Walker
WBQC= Wide Base Quad Cane WC = Wheelchair
Functional Status
Bed Mobility Assist Transfers Assist Transfers Assist Transfers Assist
Rolling Right Supine - Sit Stand - Sit Toilet
Rolling Left Sit - Supine Bed - WCSit -
Scooting Sit - Stand WC - Bed
Balance Sitting Standing Gait
Static Equipment Distance (Feet)
Dynamic Assist Weight Bearing
Gait Analysis
Assessment
Problems Plan of Treatment
Decline in Bed Mobility Bed Mobility Training
Decline in Transfers Transfer Training
Decline in Gait Progressive Gait/Stairs Training
Safety Awareness Deficits Instructions on Safety
Balance Deficits Balance Training
ROM/Strength Deficits Therapeutic Exercises (specify)
Other (specify) Patient/Caregiver/Staff Teaching Program
Other (specify)
Short Term Goals Long Term Goals
Improve Bed Mobility to: Improve Bed Mobility to:
Improve Transfers to: Improve Transfers to:
Improve Gait/Stairs Mgt. to: Improve Gait/Stairs Mgt. to:
Improve Safety Awareness to: Improve Safety Awareness to:
Improve ROM/Strength to: Improve ROM/Strength to:
Others (specify) Other (specify)
Initiate Patient/Caregiver/Staff Teaching Program Independent in Home Exercise Program; Good Return Demonstration of All
Instructions by Staff/Caregiver
Patient's Goals
Rehab Potential Tentative Discharge Plans: Home Rehab Other
Frequency/Duration of Treatment
Comments CLINICAL TESTS:
■Angiogram■Arthroscopy■ Biopsy ■ Blood tests ■ Bone scan■ Bronchoscopy ■
CT scan■ Doppler ultrasound ■ Echocardiogram ■ EEG
(electroencephalogram)■ EKG (electrocardiogram)■ EMG (electromyogram)
■Mammogram n ■ MRI■ Myelogram■ NCV (nerve conduction velocity) ■ Pap
smear ■ Pulmonary function test■ Spinal tap■ Stool tests■ Stress test (eg,
treadmill, bicycle)■ Urine tests ■ X-rays■ Other:_________
Registered Physical Therapist Date
Physician Approval Date
Date of Referral Date of Onset Treatment Diagnosis
Physical Therapy Orders
History of Present Illness
Past Medical History Heart problem-B.P-Chest problem-Stroke-Diabetes-Thyroid problem-Infectious disease- Kidney problems-
Skin diseases-GIT-UTI-Others:
Precautions
Prior Functional Level
Present Functional Level
Psychosocial History
Allergies Medications
Range of Motion/Strength Orientation Responsiveness
ROM/Strength
ROM Strength Name
Place
Time
Agitation
Language Barrier
Specify:
Alert
Lethargic
Responds to Verbal Cue
Painful Stimuli
Non-Responsive
Left Right Left Right
Upper Extremities
Prior Ambulation
Community
Household
Assist
Device
Non-Ambulatory
Follows Commands
Confused at Times
Home Environment
Alone
With Help
Board and Care
Convalescent/SN
Stairs
Safety Awareness
Poor
Fair
Good
Needs Verbal/Tactile Cues
Lower Extremities
Sensation
Pain Status
Trunk Strength/ROM Psychosocial
Tone
Coordination Barriers in Learning Endurance
Comments PATIENT IDENTIFICATION