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Initial Evaluation Yes / No
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PT/PTA Name
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Occupation
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History of present illness
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Diagnosis
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Past Medical History
• • •
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Past Surgical History
• • •
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Pain Assessment
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Location head
• • •
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Location Comments
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Quality; Sharp
• • •
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Quality Comments
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Severity
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Severity Comments
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Duration
• • •
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Duration Comments
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Onset / Timing
• • •
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Onset Comments
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Context
• • •
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Context Comments
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Modifying Factors
• • •
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Modifying Factors Comments
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Aggravating Factors
• • •
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Alleviating Factors
• • •
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Associated Symptoms
• • •
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Associated Symptoms Comments
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Previous Treatment
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Initial Evaluation Chart
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Initial Evaluation Draw
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Re-Evaluation Chart and Sketch
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Body Diagram (Cervical Spine)
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Cervical and Thoracic/Lumbar spine ROM
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Body Diagram Anatomy
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Pain/Edema
• • •
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Balance
• • •
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Manual Muscle Testing (MMT)
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Physical Therapy Functional Assessment
• • •
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Clinical Presentation
• • •
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Physical Examination:
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Joint involved
• • •
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Observation
• • •
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Palpation
• • •
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Range of Motion (ROM)
• • •
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Strength Testing
• • •
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Strength (0-5 Scale)
• • •
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MSK WNL
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MSK Abnormal
• • •
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MSK Comments
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Neuro WNL
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Neuro Comments
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Extremities WNL
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Extrem Comments
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Cervical and Lumbar Spine
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LUMBAR SPINE. ROM:
• • •
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LUMBAR SPINE. Palpation:
• • •
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Gait
• • •
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CERVICAL SPINE. ROM
• • •
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Special Testing
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Special Test 1
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Special Test 2
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Special Test 3
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Special Test 4
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Medical Problems
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Problem 1
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Problem 2
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Problem 3
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Problem 4
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Problem 5
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Assessment
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Assessment
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Treatment plan
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Exercise Treatment Plan:
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Exercise Treatment Plan 2:
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Exercise Treatment Plan 3:
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Exercise Treatment Plan 4:
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Therapeutic Goals
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Goal 1
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Goal 2
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Goal 3
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Goal 4
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Duration to Achieve Goals
• • •
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Rehabilitation Potential
• • •
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General Instructions
• • •
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Education
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PT Recommendations
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Precautions
• • •
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Progress
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