Physical Therapy Initial Evaluation Form Page 2

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Patient#_______________ Provider_______
11. WHAT ARE YOUR GOALS TO BE ACHIEVED BY THE END OF THERAPY?
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
DRAW IN AREAS OF PAIN ON BODY DIAGRAMS USING APPROPRIATE SYMBOLS. If you are completing this form on the
computer, print form after completion and mark the diagram with a pen.
*******
SEVERE PAIN
00000000
MODERATE PAIN
∩∩∩∩∩∩
DULL ACHE
↑↓↑↓↑↓↑↓
RADIATING PAIN
XXXXXX
NUMBNESS/TINGLING
MEDICAL INFORMATION (MARK ALL THAT APPLY) **THIS INFORMATION IS CONFIDENTIAL AND REMAINS PART OF
YOUR CHART
DIFFICULTY SWALLOWING
MOTION SICKNESS
STROKE
ARTHRITIS
FEVER/CHILLS/SWEATS
OSTEOPOROSIS
HIGH BLOOD PRESSURE
UNEXPLAINED WEIGHT LOSS
ANEMIA
HEART TROUBLE
BLOOD CLOTS
BLEEDING PROBLEMS
PACEMAKER
SHORTNESS OF BREATH
HIV/HEPATITIS
EPILEPSY/SEIZURES
HISTORY OF SMOKING
HISTORY OF ALCOHOL ABUSE
HISTORY OF DRUG ABUSE
DIABETES
DEPRESSION/ANXIETY
MYOFASCIAL PAIN
FIBROMYALGIA
PREGNANCY
CANCER
PREVIOUS SURGERIES:_____________________________________________________________________________________________
OTHER:___________________________________________________________________________________________________________
MEDICATIONS:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
ALLERGIES:_______________________________________________________________________________________________________

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