Physical Therapy Initial Evaluation

[YOUR COMPANY NAME]

Date: [Date]

Patient Information

Patient Name
Date of Birth
Address
Contact Number

Medical History

Chief Complain
Past Medical History
Current Medication
Surgical History
Allergies
Family History

Introduction

This evaluation will assess the patient's current condition and goals to develop an individualized treatment plan. It will facilitate our understanding of the patient's specific needs.

Overview

This comprehensive evaluation seeks to provide a structured and organized understanding of the patient's wellness objectives. It aims for an accurate assessment of their current physical performance to devise a suitable therapy plan.

Rating Scale

Ratings are based on a scale of 1 to 3, with 1 indicating inadequacy, 2 indicating moderate proficiency, and 3 indicating excellence in fulfilling the evaluation criteria. These ratings are relative and should be interpreted within the context of the specific evaluation criteria provided.

1 - Inadequate

• Signifies a minimal or insufficient level of performance.

• Indicates that the criteria are poorly addressed or not addressed at all.

• Demonstrates a lack of understanding, effort, or capability in fulfilling the evaluation criteria.

2 - Moderate Proficiency

• Represents a satisfactory but not exceptional level of performance.

• Shows some effort and competency in addressing the evaluation criteria.

• Indicates that the criteria are partially met or met to some extent, but with room for improvement.

3 - Excellent

• Reflects a high level of performance that surpasses expectations.

• Indicates thoroughness, accuracy, and effectiveness in fulfilling the evaluation criteria.

• Demonstrates a comprehensive understanding and proficient execution of the evaluation criteria.

Evaluation Criteria

Evaluation Criteria	Description	Rating
Physical Assessment	A thorough evaluation of muscle strength, joint mobility, balance, and coordination.
Goal Identification	Understanding the patient's goals and motivation for participating in physical therapy.
Functional Limitations	Identification of limitations that impact the patient's daily function or routine.
Treatment Planning	Creating a comprehensive, individualized treatment plan based on the aforementioned factors.

Additional Comments and Notes:

Observer	Comments

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