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PT EVALUATION
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Reason for Visit
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Mechanism of Injury
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Date of Accident
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History of present condition
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Investigations done
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Medications
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Allergies
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Review Of Systems
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Skin
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Cardiovascular system
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Pulmonary
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Gastrointestinal
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Neurological
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Genitourinary
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Haematological
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Lymphatics
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Endocrinology
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Psychiatric
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Gynaecological
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Sexual Relations
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Personal Injury Questions
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Patient was
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Was patient wearing seat belt
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Did airbag deploy
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Area of impact
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Did patient go to the hospital or urgent care
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Cuts/contusions
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Did patients loose consciousness
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Is the patient working at present?
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Patient's work requirement
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Concussion/TBI/PTSD
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Previous injuries, surgeries, tests and treatment
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Is previous injury/surgery contributory to present complain of pain
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Comments
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SUBJECTIVE
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Pain Assessment
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Location 1
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Pain Scale
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Quality
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Irritability
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Radiation
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Location 2
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Pain Scale
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Quality
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Irritability
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Radiation
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Location 3
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Pain Scale
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Quality
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Irritability
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Radiation
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Prior Level of Functioning
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Level of Assistance
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Sitting
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Standing
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Walking
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Lifting
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Working
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Self Care
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Current Level of Function
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Level of Assistance
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Sitting
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Standing
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Walking
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Lifting
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Working
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Self Care
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Patient Goals
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Comments
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OBJECTIVE
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General Physical Exam
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Height
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Weight
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Pulse
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Blood pressure
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Posture
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Gait
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Neurologic
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Inspection
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Sleep
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Comments
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PT Examination
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Spine/Sacroiliac Joint
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Tenderness
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Trigger points
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Muscle spasm
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Abdominal Strength
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Lumbar Extensors Strength
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Range of Motion
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Dermatomes
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Myotomes
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Deep Tendon Reflexes
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Special Tests
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Deep neck flexor endurance test
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Shoulder
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ST
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Tenderness
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Trigger points
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Muscle spasm
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Range of Motion
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Manual Muscle Testing
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Shoulder strength
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Special Tests
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Comments
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Special Tests
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Elbow
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Tenderness
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Range of Motion
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Manual Muscle Testing
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Special Tests
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Comments
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Hand and Wrist
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Tenderness
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Muscle spasm
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Range of Motion
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Manual Muscle Testing
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Special Tests
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Comments
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Hip
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Tenderness
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Muscle spasm
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Trigger points
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Range of Motion
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Manual Muscle Testing
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Special Tests
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Comments
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Knee
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Tenderness
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Trigger points
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Muscle spasm
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Range of Motion
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Manual muscle Testing
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Special Tests
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Comments
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Foot and Ankle
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Special Tests
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Tenderness
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Trigger points
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Muscle spasm
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Range of Motion
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Manual Muscle Testing
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Special Tests
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Comments
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Outcome Scale 1
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Outcome scale 2
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Outcome scale 3
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ASSESSMENT
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PT Diagnosis
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PLAN OF CARE
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Plan Of Care
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Frequency
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Duration (weeks)
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Precautions
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Short Term Goals
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Long Term Goals
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Additional Short term goals
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Additional Long term goals
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