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PT Re-evaluation (to be done very 3-4 months)
Time (frequency and # of months) participating in Able Bionics program
SUBJECTIVE Intake
Important updates/ Events since last evaluation
Any physical changes noticed by client or caregivers
Pain
Falls since last evaluation
Current Home Exercise Program
Medication changes since last evaluation
Other current therapies
Cannabis/ CBD Use?
Other
OBJECTIVE
Spine: (ROM, scoliosis)
Core strength
Balance
Other
Transfers
Client Survey Response
ABC Scale
Quality of Life Scale
UE spasticity
Elbow flex - L
Elbow flex - R
Elbow ext - L
Elbow ext - R
Wrist flex - L
Wrist flex - R
Wrist ext - L
Wrist ext - R
Other - L
Other - R
UE Spasticity Comments
Shoulder AROM/PROM
AROM/PROM
• • •
Flexion - L
Flexion - R
Extension - L
Extension - R
External Rotation - L
External Rotation - R
Internal Rotation - L
Internal Rotation - R
Abduction - L
Abduction - R
Elbow AROM/PROM
AROM/PROM
• • •
Flexion - L
Flexion - R
Extension - L
Extension - R
Supination - L
Supination - R
Pronation - L
Pronation - R
Wrist AROM/PROM
AROM/PROM
• • •
Flexion - L
Flexion - R
Extension - L
Extension - R
Shoulder Strength
Flexion - L
Flexion - R
Extension - L
Extension - R
External Rotation - L
External Rotation - R
Internal Rotation - L
Internal Rotation - R
Abduction - L
Abduction - R
Elbow Strength
Flexion - L
Flexion - R
Extension - L
Extension - R
Supination - L
Supination - R
Pronation - L
Pronation - R
Wrist Strength
Flexion - L
Flexion - R
Extension - L
Extension - R
Upper extremity comments
LE Spacticity
Hip flex - L
Hip flex - R
Hip ext - L
Hip ext - R
Hip add - L
Hip add - R
Knee flex - L
Knee flex - R
Knee ext - L
Knee ext - R
Plantar flex - L
Plantar flex - R
Dorse Flex - L
Dorse Flex - R
Hip AROM/PROM
AROM/PROM
• • •
Flexion - L
Flexion - R
Extension - L
Extension - R
Internal Rotation - L
Internal Rotation - R
External Rotation - L
External Rotation - R
Abduction - L
Abduction - R
Adduction - L
Adduction - R
Knee/Ankle AROM/PROM
AROM/PROM
• • •
Extension - L
Extension - R
Flexion - L
Flexion - R
Ankle Dorsi - L
Ankle Dorsi - R
Ankle Plantar - L
Ankle Plantar - R
Ankle Inversion - L
Ankle Inversion - R
Ankle Eversion - L
Ankle Eversion - R
Hip Strength
Flexion - L
Flexion - R
Extension - L
Extension - R
Internal Rotation - L
Internal Rotation - R
External Rotation - L
External Rotation - R
Abd - L
Abd - R
Add - L
Add - R
Knee/Ankle Strength
Extension - L
Extension - R
Flexion - L
Flexion - R
Ankle Dorsi - L
Ankle Dorsi - R
Ankle Plantar - L
Ankle Plantar - R
Ankle Inversion - L
Ankle Inversion - R
Ankle Eversion - L
Ankle Eversion - R
Lower Extremity Comments
Balance
Berg Balance Scale
Tinetti Test (Gait and Balance)
TUG
Sitting balance
Mini- Best
Gait
6 min walk test
Description of Gait quality
10 MWT
Comments
PT ASSESSMENT
Assessment
PT PLAN
Plan
Goals
Goals
Goals
Goals
Goals
Goals

Client Re-Evaluation Form Medical Form

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Published: May 7, 2020, 4:49 p.m.
Provider: Dr. History Physical
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