Physical Therapy Evaluation Form [PDF]

Citation preview

Date of Referral



Date of Onset



      Physical Therapy Orders History of Present Illness



Treatment Diagnosis



                 



     



            Past Medical History



     



                 



Precautions



      Prior Functional Level



     



                 



Present Functional Level Psychosocial History Allergies



Medications



     



Range of Motion/Strength ROM Strength ROM/Strength Left Right Left Right Upper Extremities                    



           



           



         



         



         



         



Name Place Time Agitation Language Barrier Specify:



     



    



    



    



    



                             



                             



                                  



                                  



                                  



                                  



                                  



                                  



                                  



                                              



                                               



                                               



Responsiveness Alert Lethargic Responds to Verbal Cue Painful Stimuli Non-Responsive



     



     



     



Lower Extremities



     



Orientation



Follows Commands Confused at Times Home Environment



Prior Ambulation Community Household Assist Device       Non-Ambulatory



Alone



Safety Awareness



With Help       Board and Care Convalescent/SN Stairs Sensation



Poor Fair Good Needs Verbal/Tactile Cues Pain Status



     



Trunk Strength/ROM



Psychosocial



     



Tone



            Coordination



     



                  Comments



Barriers in Learning



     



     



                  Rehabilitation Therapy



Physical Therapy Evaluation T3808-T Rev. (09/30/2003) Page 1 of 2



Endurance



     



PATIENT IDENTIFICATION



Codes



NT 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 CR = Crutches SPC = Single Point Cane NBQC= Narrow Base Quad Cane WBQC= Wide Base Quad Cane



HW SW FWW 4WW WC



= Hemiwalker = Standard Walker = Front Wheel Walker = Four Wheel Walker = Wheelchair



Functional Status Bed Mobility



Assist



Transfers Supine - Sit



Rolling Left



           



Scooting



     



Rolling Right



Balance



Sitting



Static



           



Dynamic



Assist



Transfers



Assist



Stand - Sit



Sit - Supine



           



Bed - WCSit -



           



Sit - Stand



     



WC - Bed



     



Transfers Toilet



Standing



           



Gait Equipment Assist



           



Distance (Feet) Weight Bearing



Gait Analysis



            Assessment Problems



           



Decline in Bed Mobility Decline in Transfers Decline in Gait       Safety Awareness Deficits Balance Deficits       ROM/Strength Deficits



     



            Other (specify)



     



     



Plan of Treatment Bed Mobility Training Transfer Training Progressive Gait/Stairs Training Instructions on Safety Balance Training Therapeutic Exercises (specify)



           



     



Patient/Caregiver/Staff Teaching Program



           



Assist



     



Other (specify)



                 



     



           



Short Term Goals Improve Bed Mobility to:       Improve Transfers to:       Improve Gait/Stairs Mgt. to:       Improve Safety Awareness to:       Improve ROM/Strength to:       Others (specify)      



Long Term Goals Improve Bed Mobility to:       Improve Transfers to:       Improve Gait/Stairs Mgt. to:       Improve Safety Awareness to:       Improve ROM/Strength to:       Other (specify)      



           



            Independent in Home Exercise Program; Good Return Demonstration of All Instructions by Staff/Caregiver



Initiate Patient/Caregiver/Staff Teaching Program Patient's Goals



     



            Rehab Potential



     



Frequency/Duration of Treatment Comments



Tentative Discharge Plans:



Home



Rehab



Other      



     



     



PATIENT IDENTIFICATION



            Registered Physical Therapist



Date



Physician Approval



Date



Rehabilitation Therapy



Physical Therapy Evaluation T3808-T Rev. (09/30/2003) Page 2 of 2



Physical, Occupational & Speech Therapy Evaluations



Guidelines



Form #T3808-T Procedure: 



Disability specific addendum sheet may be required.







List additional discipline specific standardized tests performed (i.e., home evaluations, vestibular testing, etc.) as follows and attach results: Physical Therapy T3808 in the Comments section at the bottom of page two; Occupational Therapy T3809 in the Comments section at the bottom of page two; Speech Therapy T3810 in the Addendum Evaluations section at the bottom.







Prepared By (Name/Title): signature(s) of the staff member(s) who complete(s) Summary of Client Progress or Recommendations.







Initial & Signature/Title Section: (at the bottom) is to be completed by all reviewing therapists and social workers







If an addressograph is not available, hand write patient’s name in the Patient Identification area



T3808-T Rev. (09/30/2003)