Physical Therapy Initial Evaluation and Plan of Care

Form to document the initial physical therapy examination, clinical impression, prognosis, measurable functional goals, and the planned frequency and duration of care before treatment begins.

Patient and Referral Information

• Patient Name
• Medical Record Number
  Optional internal identifier if needed for chart matching.
• Date of Birth
  Collect only if needed to confirm identity and avoid duplicate records.
• Referring Provider
• Referral Date
• Evaluation Date

Reason for Referral and Subjective History

• Primary Complaint
  Briefly describe the main reason for physical therapy evaluation.
• Date of Onset or Injury
• Mechanism of Injury or Symptom Onset
• Pain Location
• Pain Severity
• Aggravating Factors
• Relieving Factors
• Functional Limitations
  Describe how the condition affects activities of daily living, work, mobility, or participation.

Objective Examination

• Posture and Observation
• Range of Motion Findings
• Strength Findings
• Neurological Screen
• Special Tests and Clinical Tests
• Assistive Device Use

Assessment, Diagnosis, and Prognosis

• Clinical Impression
• Physical Therapy Diagnosis
  Document the PT diagnosis or movement dysfunction, not a billing code unless required by your workflow.
• Prognosis
• Barriers to Recovery

Measurable Goals and Plan of Care

• Short-Term Goals
  Enter measurable goals with a target timeframe.
• Long-Term Goals
  Enter measurable discharge goals with functional outcomes.
• Treatment Frequency per Week
• Planned Episode Duration (Weeks)
• Planned Interventions

Consent, Disclosure, and Submission

• PII and Health Information Disclosure Acknowledgment
  I understand this form collects limited PII and health information for treatment planning, documentation, and audit trail purposes.
• Consent to Documentation
  I confirm the information provided is accurate to the best of my knowledge and may be used to establish the plan of care.
• Clinician Name
• Clinician Title
• Clinician Signature
• Submission Notes
  Optional notes for reviewers, authorization staff, or the care team.