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Run: Therapy Evaluation and Plan of Care

Therapy Evaluation and Plan of Care template for documenting the initial physical therapy evaluation, clinical findings, goals, and treatment plan in one str...

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Patient and Referral Information

Patient Name (required)

Medical Record Number

Use only if needed to match the evaluation to the correct chart.

Date of Evaluation (required)

Referral Source (required)

Reason for Referral (required)

Subjective History and Consent

Chief Complaint / Primary Therapy Concern (required)

Onset Date

Precautions / Restrictions

Consent to Document Evaluation (required)

I understand this form collects clinical information needed for treatment planning and documentation.

Yes No N/A

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 (required)

Rehabilitation Potential (required)

Goals and Plan of Care

Short-Term Goals (required)

Long-Term Goals (required)

Recommended Frequency and Duration (required)

Planned Interventions (required)

Discharge Planning Considerations

Clinician Attestation and Submission

Clinician Name (required)

Credentials (required)

Electronic Signature (required)

Attestation (required)

I attest that this evaluation reflects my clinical findings and plan of care.

Yes No N/A

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Email (required)

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