Initial Physical Therapy Evaluation
This initial evaluation establishes a baseline for your physical therapy episode of care. We will review your history, examine the relevant systems, and design a plan that fits your goals.
Emergency contact (name + phone):
Surgical history (date / procedure / surgeon, if relevant):
[Issuer fills this in at creation]
In your own words, describe the problem that brought you in:
Specific incident or context (if any):
Specific incident or context (if any):
[Issuer fills this in at creation]
Worst pain this week (0-10):
Best pain this week (0-10):
Location and referral pattern (describe in detail):
Body diagram description (markings shown to therapist):
Aggravating factors (positions, movements, activities):
Relieving factors (rest, ice, medication, position):
Relieving factors (rest, ice, medication, position):
[Issuer fills this in at creation]
Relevant conditions (diabetes, vascular, cardiac, neurological, etc.):
Current medications (name / dose / frequency):
Previous physical therapy for this complaint:
If yes, when, where, and what was the outcome?
If yes: when, where, and with what result?
[Issuer fills this in at creation]
Postural / Observational Assessment
Posture in standing (anterior / posterior / lateral views):
Gait observation (cadence, stride, asymmetry, deviations):
[Issuer fills this in at creation]
Range of Motion (ROM) — Active and Passive
For each motion, record AROM and PROM in degrees, end-feel, and whether pain is reproduced.
Shoulder flexion — AROM: PROM: End-feel: Pain reproduced:
Shoulder abduction — AROM: PROM: End-feel: Pain reproduced:
Shoulder external rotation — AROM: PROM: End-feel: Pain reproduced:
Shoulder internal rotation — AROM: PROM: End-feel: Pain reproduced:
Elbow flexion — AROM: PROM: End-feel: Pain reproduced:
Wrist extension — AROM: PROM: End-feel: Pain reproduced:
Shoulder flexion — AROM: PROM:
Shoulder abduction — AROM: PROM:
Shoulder external rotation — AROM: PROM:
Shoulder internal rotation — AROM: PROM:
Elbow flexion — AROM: PROM:
Wrist extension — AROM: PROM:
Manual Muscle Testing (MMT 0-5)
Grade 0 = no contraction, 5 = full strength against maximal resistance.
Muscle 1: Grade: Pain reproduction:
Muscle 2: Grade: Pain reproduction:
Muscle 3: Grade: Pain reproduction:
Muscle 4: Grade: Pain reproduction:
Muscle 5: Grade: Pain reproduction:
Muscle 6: Grade: Pain reproduction:
Up to 6 entries (e.g. SLR, Phalen, Empty Can, Spurling, Drop Arm, Lachman) — record positive / negative and any pertinent findings.
[Issuer fills this in at creation]
Activities of daily living (ADLs) impacted — select all that apply.
Specific impacted activities (describe):
Outcome Measures (Baseline)
Selected outcome measure (Oswestry / DASH / KOOS / LEFS / Tampa Scale of Kinesiophobia):
In your own words — what does success look like for you?
[Issuer fills this in at creation]
Therapist Clinical Impression
Working hypothesis, contributing factors, prognostic indicators:
[Issuer fills this in at creation]
Initial direction for treatment, expected episode length, and key milestones:
[Issuer fills this in at creation]
Thank you for completing this evaluation. Your therapist will use this information together with the examination findings to design a plan of care tailored to your goals.