PHYSICAL THERAPY INITIAL EVALUATION FORM

DATE: _____________

PATIENT DEMOGRAPHICS
Name ____________ Occupation ____________ Contact no. _____________

Age Email Address_________________ Residence ___________

Newborn -20 years

21 years – 40 years

41 years – 60 years

61 years – 80 years

80years above

Subjective Data
Chief complaint/ailment/injury ____________________________________________

Mechanism of injury _____________________________________________________

______________________________________________________________________

Region of pain
Cervical Upper limb (elbow) Lower limb(hip)

Thoracic Upper limb ( shoulder) Lower limb (knee)

Lumbar/low back Upper limb ( wrist and fingers) Lower limb( ankle and foot)

Have you had any surgery before? YES NO

If yes then which surgery? ___________________________________________________

Have you received therapy for this condition? YES NO

WHEN? ______

Has your condition been getting: WORSE SAME BETTER

Are your symptoms: Constant Intermittent

What time of day do you usually feel pain? Day Night After exertion only

Mark the number that best corresponds to your pain:

At best 0 1 2 3 4 5 6 7 8 9 10
At worst: 0 1 2 3 4 5 6 7 8 9 10

What are the relieving factors?

Resting
Sitting
Standing
Bending
Lying
Ice
Heat
Others ______________________________
What are the aggravating factors?
Resting
Sitting
Standing
Bending
Lying
Walking
Others ______________________________
Radiological findings
X- ray
MRI
CT scan
Dexa Scan
Others ______________________________

What type of pain do you feel?

Severe pain
Moderate pain
Dull ache
Radiating pain
Numbness/tingling
Past Medical History ( Co morbidity)
Diabetes Mellitus
Hypertension
Stroke
Cholesterol
Anemia
Fibromyalgia
Others _____________________________________________________________
Are you currently taking any medicines? YES NO
If yes then which medicines, ___________________________________________________

OBJECTIVE DATA
INSPECTION AND PALPATION
Inflammation: Yes No

Swelling Yes No

Tenderness: Yes No

Crepitus: Yes No

Range of motion: Increased Decreased Restricted

Muscle strength: Increased Decreased

Muscle tone: Increased Decreased

 EVALUATION
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
 FOOT ASSESSMENT
Do you have pain in your foot? YES NO
How is your arch? Normal arch High arch low arch

Is leg length discrepancy present? YES NO

Is there any foot deformity present? YES NO

What footwear do you use for daily wear?

o Sandals
o Chappals
o Joggers
o Sneakers
o Heels
o Wedges
Others ______________________

Comments :
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
 TREATMENT GOALS
Short term goals
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Long term goals
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
TREATMENT PLAN
Day 1
______________________________________________________________________________
______________________________________________________________________________
Day 2
______________________________________________________________________________
______________________________________________________________________________
Day 3
______________________________________________________________________________
______________________________________________________________________________
Day 4
______________________________________________________________________________
______________________________________________________________________________
Day 5
______________________________________________________________________________
______________________________________________________________________________
Day 6
______________________________________________________________________________
______________________________________________________________________________
Day7
______________________________________________________________________________
______________________________________________________________________________