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.

Patient Demographics

Full name:

Date of birth:

Gender:

Occupation:

Dominant hand:

Height: Weight:

Contact phone / email:

Emergency contact (name + phone):

Referral Information

Referring physician:

Referral diagnosis:

ICD-10 code:

Referral date:

Surgical history (date / procedure / surgeon, if relevant):

Chief Complaint

In your own words, describe the problem that brought you in:

Onset date:

Mechanism of injury:

Specific incident or context (if any):

Pain Assessment

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:

Past Medical History

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?

Postural / Observational Assessment

Posture in standing (anterior / posterior / lateral views):

Gait observation (cadence, stride, asymmetry, deviations):

Walking aid in use:

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:

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:

Special Tests

Up to 6 entries (e.g. SLR, Phalen, Empty Can, Spurling, Drop Arm, Lachman) — record positive / negative and any pertinent findings.

Functional Limitations

Activities of daily living (ADLs) impacted — select all that apply.

Impacted ADLs:

Specific impacted activities (describe):

Outcome Measures (Baseline)

Selected outcome measure (Oswestry / DASH / KOOS / LEFS / Tampa Scale of Kinesiophobia):

Baseline score:

Patient Goals

In your own words — what does success look like for you?

Therapist Clinical Impression

Working hypothesis, contributing factors, prognostic indicators:

Plan-of-Care Direction

Initial direction for treatment, expected episode length, and key milestones:

Acknowledgement

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.