Free Physical Therapy Evaluation Template
Physical Therapy Evaluation
[YOUR COMPANY NAME]
Patient's Information:
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Name: |
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Age: |
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Gender: |
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Date of Birth: |
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Contact Information: |
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Referring Physician: |
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Date of Referral: |
Date: [DATE]
Introduction:
This comprehensive evaluation form is designed to make a thorough assessment of any musculoskeletal or neurological impairments affecting mobility and function.
Overview:
It diagnoses conditions, develops treatment plans, monitors progress, evaluates functional capacity, and promotes patient empowerment through education. This holistic evaluation aims to maximize rehabilitation results and boost the quality of life.
Criteria:
The assessment of musculoskeletal and neurological function includes the following criteria: objective evaluations, subjective reports, and clinical observations. This multifaceted approach is designed to yield a detailed understanding of the patient's condition and treatment progress.
Rating Scale: 1 = Poor, 2 = Fair, 3 = Good, 4 = Very Good, 5 = Excellent
Evaluation
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Evaluation Criteria |
Description |
Rating (1-5) |
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Objective Assessments |
These are evaluations carried out using standardized tests and measures to provide an empirical basis for diagnosing musculoskeletal or neurological impairments. |
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Subjective Reports |
This criterion pertains to the patient's account of their symptoms and experiences, providing valuable data on the effect of the impairments on their everyday life and well-being. |
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Clinical Observations |
These are based on the healthcare practitioner's professional observations and clinical experience, which can provide deeper insights into the patient's condition and response to treatment. |
Additional Comments and Notes
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Area |
Comments |
Notes |
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