Free Home Health Physical Therapy Evaluation Template
Home Health Physical Therapy Evaluation
[YOUR COMPANY NAME]
Date: [DATE]
Introduction: This evaluation form has been carefully designed to assess your health status and functional abilities in the comfort of your home. It serves as a crucial tool in creating a personalized treatment plan to address your specific needs and improve your overall well-being. Please take your time to fill in the following information accurately, as it will assist our licensed physical therapists in conducting a comprehensive evaluation.
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Home Health Physical Therapy Evaluation Form |
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Patient Information |
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Full Name: |
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Date of Birth: |
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Health Status |
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Current Medications: |
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Known Allergies: |
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Past Surgeries: |
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Functional Evaluation |
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Mobility: |
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Balance and Coordination: |
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Fine Motor Skills: |
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Functional Limitations |
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Difficulty in Moving: |
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Difficulty in Performing Daily Activities: |
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Any Other Functional Limitations: |
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Objective Measures |
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Blood Pressure (BP): |
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Heart Rate (HR): |
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Respiratory Rate (RR): |
Confidentiality Notice: The information provided will be treated with utmost confidentiality and will only be utilized to create an individualized treatment plan for the patient.
