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SUBJECTIVE Intake
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Prior Level of Function
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History of Present Injury
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Injury/Diagnosis
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DOI/Date of Diagnosis
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Referring Doctor
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Relevant past medical history
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History of joint replacements
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Living Environment
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Current Standing Program
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Gait function, endurance, assistive devices, brace use
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Current Skin Integrity
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Past problems with skin integrity
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Sensation
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Pain
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Issues with Orthostatic hypotension/Vasovagal issues
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History of Falls
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Other therapies client is involved with
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Presence of catheter/feeding tube/baclofen pump/other
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Current Medications
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Cannabis/ CBD Use?
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Other
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OBJECTIVE
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Spine: (ROM, scoliosis)
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Core strength
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Balance
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Other
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Transfers
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Client Survey Response
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ABC Scale
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Quality of Life Scale
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SCIM
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SCIM
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UE spasticity
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Elbow flex - L
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Elbow flex - R
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Elbow ext - L
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Elbow ext - R
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Wrist flex - L
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Wrist flex - R
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Wrist ext - L
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Wrist ext - R
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Other - L
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Other - R
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UE Spasticity Comments
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Shoulder AROM/PROM
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AROM/PROM
• • •
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Flexion - L
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Flexion - R
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Extension - L
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Extension - R
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External Rotation - L
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External Rotation - R
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Internal Rotation - L
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Internal Rotation - R
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Abduction - L
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Abduction - R
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Elbow AROM/PROM
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AROM/PROM
• • •
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Flexion - L
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Flexion - R
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Extension - L
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Extension - R
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Supination - L
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Supination - R
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Pronation - L
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Pronation - R
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Wrist AROM/PROM
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AROM/PROM
• • •
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Flexion - L
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Flexion - R
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Extension - L
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Extension - R
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Shoulder Strength
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Flexion - L
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Flexion - R
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Extension - L
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Extension - R
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Internal Rotation - L
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External Rotation - R
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Internal Rotation - L
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Internal Rotation - R
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Abduction - L
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Abduction - R
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Elbow Strength
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Flexion - L
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Flexion - R
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Extension - L
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Extension - R
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Supination - L
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Supination - R
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Pronation - L
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Pronation - R
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Wrist Strength
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Flexion - L
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Flexion - R
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Extension - L
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Extension - R
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Upper extremity comments
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LE Spacticity
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Hip flex - L
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Hip flex - R
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Hip ext - L
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Hip ext - R
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Hip add - L
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Hip add - R
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Knee flex - L
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Knee flex - R
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Knee ext - L
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Knee ext - R
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Plantar flex - L
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Plantar flex - R
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Dorse Flex - L
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Dorse Flex - R
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Hip AROM/PROM
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AROM/PROM
• • •
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Flexion - L
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Flexion - R
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Extension - L
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Extension - R
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Internal Rotation - L
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Internal Rotation - R
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External Rotation - L
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External Rotation - R
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Abduction - L
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Abduction - R
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Adduction - L
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Adduction - R
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Knee/Ankle AROM/PROM
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AROM/PROM
• • •
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Extension - L
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Extension - R
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Flexion - L
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Flexion - R
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Ankle Dorsi - L
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Ankle Dorsi - R
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Ankle Plantar - L
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Ankle Plantar - R
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Ankle Inversion - L
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Ankle Inversion - R
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Ankle Eversion - L
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Ankle Eversion - R
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Hip Strength
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Flexion - L
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Flexion - R
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Extension - L
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Extension - R
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Internal Rotation - L
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Internal Rotation - R
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External Rotation - L
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External Rotation - R
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Abd - L
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Abd - R
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Add - L
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Add - R
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Knee/Ankle Strength
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Extension - L
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Extension - R
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Flexion - L
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Flexion - R
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Ankle Dorsi - L
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Ankle Dorsi - R
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Ankle Plantar - L
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Ankle Plantar - R
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Ankle Inversion - L
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Ankle Inversion - R
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Ankle Eversion - L
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Ankle Eversion - R
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Lower Extremity Comments
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Balance
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Berg Balance Scale
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Tinetti Test (Gait and Balance)
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TUG
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Sitting balance
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Mini- Best
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Gait
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6 min walk test
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Description of Gait quality
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10 MWT
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Comments
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PT Assessment
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PT Plan
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Assessment
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Plan
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Goals
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Goals
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Goals
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Goals
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Goals
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Goals
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