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______________________________________________________

Patient#_______________ Provider_______

11. WHAT ARE YOUR GOALS TO BE ACHIEVED BY THE END OF THERAPY?________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

DRAW IN AREAS OF PAIN ON BODY DIAGRAMS USING APPROPRIATE SYMBOLS. If you are completing this form on the computer, print form after completion and mark the diagram with a pen.

Patient#_______________ Provider_______

SEVERE PAIN *******

MODERATE PAIN 00000000

DULL ACHE

RADIATING PAIN

NUMBNESS/TINGLING XXXXXX

MEDICAL INFORMATION (MARK ALL THAT APPLY) **THIS INFORMATION IS CONFIDENTIAL AND REMAINS PART OF YOUR CHART

DIFFICULTY SWALLOWING MOTION SICKNESS STROKE

ARTHRITIS FEVER/CHILLS/SWEATS OSTEOPOROSIS

HIGH BLOOD PRESSURE UNEXPLAINED WEIGHT LOSS ANEMIA

HEART TROUBLE BLOOD CLOTS BLEEDING PROBLEMS

PACEMAKER SHORTNESS OF BREATH HIV/HEPATITIS

EPILEPSY/SEIZURES HISTORY OF SMOKING HISTORY OF ALCOHOL ABUSE

HISTORY OF DRUG ABUSE DIABETES DEPRESSION/ANXIETY

MYOFASCIAL PAIN FIBROMYALGIA PREGNANCY

CANCER

PREVIOUS SURGERIES:_____________________________________________________________________________________________

OTHER:___________________________________________________________________________________________________________

MEDICATIONS:

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

ALLERGIES:_______________________________________________________________________________________________________

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