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Run: Physical Therapy Initial Evaluation and Plan of Care

Document the initial physical therapy evaluation, clinical impression, measurable goals, and plan of care in one structured intake form. Use it to capture th...

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Patient and Referral Information

Patient Name (required)

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 (required)

Reason for Referral and Subjective History

Primary Complaint (required)

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 (required)

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 (required)

Physical Therapy Diagnosis (required)

Document the PT diagnosis or movement dysfunction, not a billing code unless required by your workflow.

Prognosis (required)

Barriers to Recovery

Measurable Goals and Plan of Care

Short-Term Goals (required)

Enter measurable goals with a target timeframe.

Long-Term Goals (required)

Enter measurable discharge goals with functional outcomes.

Treatment Frequency per Week (required)

Planned Episode Duration (Weeks) (required)

Planned Interventions (required)

Consent, Disclosure, and Submission

PII and Health Information Disclosure Acknowledgment (required)

I understand this form collects limited PII and health information for treatment planning, documentation, and audit trail purposes.

Yes No N/A

Consent to Documentation (required)

I confirm the information provided is accurate to the best of my knowledge and may be used to establish the plan of care.

Yes No N/A

Clinician Name (required)

Clinician Title (required)

Clinician Signature (required)

Submission Notes

Optional notes for reviewers, authorization staff, or the care team.

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Email (required)

Your name (optional)

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