Therapy Evaluation and Plan of Care

Initial physical therapy evaluation form for documenting patient status, functional limitations, clinical findings, goals, and a plan of care.

Patient and Referral Information

• Patient Name
• Medical Record Number
  Use only if needed to match the evaluation to the correct chart.
• Date of Evaluation
• Referral Source
• Reason for Referral

Subjective History and Consent

• Chief Complaint / Primary Therapy Concern
• Onset Date
• Precautions / Restrictions
• Consent to Document Evaluation
  I understand this form collects clinical information needed for treatment planning and documentation.

Objective Examination

• Vital Signs Summary
• Pain Level
• Range of Motion Findings
• Strength Findings
• Balance Findings
• Gait / Mobility Findings

Functional Status and Clinical Assessment

• Transfer Status
• Ambulation Status
• Assistive Devices Used
• Functional Limitations
• Clinical Impression
• Rehabilitation Potential

Goals and Plan of Care

• Short-Term Goals
• Long-Term Goals
• Recommended Frequency and Duration
• Planned Interventions
• Discharge Planning Considerations

Clinician Attestation and Submission

• Clinician Name
• Credentials
• Electronic Signature
• Attestation
  I attest that this evaluation reflects my clinical findings and plan of care.