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
Get started with PocperInitial evaluation, treatment plan and goals, daily treatment notes, progress re-assessment, and discharge summary with home program for outpatient physical therapy and rehabilitation clinics
Get started with PocperThis 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.
Full name:
Date of birth:
Gender:
Occupation:
Dominant hand:
Height: Weight:
Contact phone / email:
Emergency contact (name + phone):
Referring physician:
Referral diagnosis:
ICD-10 code:
Referral date:
Surgical history (date / procedure / surgeon, if relevant):
In your own words, describe the problem that brought you in:
Onset date:
Mechanism of injury:
Specific incident or context (if any):
Current pain (VAS 0-10):
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):
Character of pain:
Aggravating factors (positions, movements, activities):
Relieving factors (rest, ice, medication, position):
Pain pattern:
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?
Posture in standing (anterior / posterior / lateral views):
Gait observation (cadence, stride, asymmetry, deviations):
Walking aid in use:
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:
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.
Activities of daily living (ADLs) impacted — select all that apply.
Impacted ADLs:
Specific impacted activities (describe):
Selected outcome measure (Oswestry / DASH / KOOS / LEFS / Tampa Scale of Kinesiophobia):
Baseline score:
In your own words — what does success look like for you?
Working hypothesis, contributing factors, prognostic indicators:
Initial direction for treatment, expected episode length, and key milestones:
The information I have provided is accurate and complete to the best of my knowledge
I agree to participate in this physical therapy evaluation
I understand that the plan of care will be discussed and agreed with me before treatment begins
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.
The Initial Physical Therapy Evaluation template is a ready-to-use form from Pocper's Physical Therapy Clinic pack. Customize the fields to match your workflow, then share a link so clients can complete it and upload documents in real time.