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Physical Therapy Initial Evaluation Form - Free Healthcare Template | ZenBuild | ZenBuild

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Physical Therapy Initial Evaluation Form

Gather functional history, pain assessment, and treatment goals for new physical therapy patients.

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Physical Therapy Initial Evaluation Form

Gather functional history, pain assessment, and treatment goals for new physical therapy patients.

Patient Full Name*

Referring Physician

Describe your main complaint or reason for seeking physical therapy*

Current pain level at rest (1 = no pain, 5 = severe pain)*

Current pain level during activity (1 = no pain, 5 = severe pain)*

Which functional activities are limited by your condition? (select all that apply)*

WalkingClimbing stairsDrivingReaching overheadLifting or carryingWork-related tasks

What are your rehabilitation goals?

Template Details

CategoryHealthcare

IndustryHealthcare

Fields7

Uses0

Views0

healthcarephysical-therapyrehabilitationevaluationmusculoskeletal