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Physical Therapy Clinic

Initial evaluation, treatment plan and goals, daily treatment notes, progress re-assessment, and discharge summary with home program for outpatient physical therapy and rehabilitation clinics

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Patient Rehab Record


This is your standing chart with our clinic — one copy that you and your therapist keep current across every episode of care. It is not a per-visit note. Update it whenever something changes: new medication, new surgery, a new referral, a change of insurance.

Patient Identity & Contact

Full name:
Date of birth:
Patient / chart number:
Mobile phone:
Email:
Home address:
Occupation / main daily physical demands:
Patient since:

Emergency Contact

Name:
Relationship:
Phone:

Referring Physician & Care Team

Referring physician / surgeon:
Clinic / hospital:
Referral phone / fax:
General practitioner (if different):
Other clinicians involved (orthopaedic, rheumatology, pain clinic, chiropractic, personal trainer):

Insurance & Payer Details

Primary insurer:
Policy / member number:
Authorisation number:
Visits authorised / used this year:
Authorisation expires:
Secondary payer, workers-compensation or auto claim details:

Permanent Medical History

Surgeries and dates, fractures, significant injuries — anything permanent that shapes how we treat you.
Imaging on file (X-ray, MRI, CT, ultrasound) — type, region, date and findings:
Comorbidities that affect exercise tolerance (diabetes, cardiac disease, asthma, arthritis, neurological conditions):

Current Medications & Allergies

Medications, dose and what each is for (include blood thinners and steroids):
Allergies and sensitivities (latex, adhesive tape, topical gels, medication):
Medications last reviewed:

Standing Precautions & Red Flags

Every therapist who treats you reads this section first. Tick everything that applies and keep it current.
Weight-bearing restriction in force
Range-of-motion or brace limits after surgery
Cardiac condition — heart-rate or exertion ceiling
Osteoporosis / low bone density — no high-impact or end-range mobilisation
Pregnant or recently post-partum
Dizziness, fainting or blood-pressure instability
Pacemaker, implanted device or metalwork — electrotherapy restrictions
Impaired skin sensation or open wound in a treated area
Detail of the precautions ticked above, and who set them:

Episode-of-Care Log

One row per episode of care — from first evaluation to discharge. Add a row each time you come back to us.
Start
End
Body region / diagnosis
Therapist
Visits
Outcome at discharge































Outcome-Measure History

Cumulative scores across all episodes — Oswestry, DASH, LEFS, numeric pain rating, timed-up-and-go, single-leg hop. Keeping them in one table makes the long-term trend visible at a glance.
Measure
Date
Score
Notes

































Equipment Issued

Item
Date issued
Returned / replaced
















Documents on File

Upload imaging reports, referral letters, operative notes, insurance authorisations and any specialist correspondence.
Upload File

Scheduling & Communication Preferences

Preferred days and times:
Preferred therapist (if any):
How we should reach you:
Text message
Email
Phone call
Interpreter or accessibility support needed — detail below

Ongoing Therapist Notes

Dated entries as things change — a new flare, a change in work duties, a return to sport, a decision agreed with the referring physician. Newest at the top.

Keep this record current — it is the chart every therapist in the clinic works from.
Use this template

Templates in this pack

The Physical Therapy Clinic pack includes 7 ready-to-use templates. Each one is a structured, fully editable form you can share with clients to collect information, documents, and signatures in one place.

Frequently asked questions

What's included in the Physical Therapy Clinic templates?
The Physical Therapy Clinic pack contains 7 templates: Patient Rehab Record, Initial Physical Therapy Evaluation, Treatment Plan & Goals, Daily Treatment Note, Progress Re-Assessment, Discharge Summary & Home Program, Clinic Services & Rehab Guide. Each is ready to use and fully editable.
Can I customize these templates?
Yes. Every Pocper template is fully editable — add or remove fields, change the wording, and adapt each form to your workflow before sharing it with clients.
How do I use the Physical Therapy Clinic templates?
Import the pack into your Pocper workspace, open a template, tailor it to your needs, then share a link so clients can fill it out and upload documents in real time.