Physical Therapy Assessment Form

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PHYSICAL THERAPY ASSESSMENT
PHYSICAL THERAPY PATIENT/CLIENT MANAGEMENT
Today’s Date: ______________
Name:_____________________________________________
Last
Please rate your health:
____ Excellent ____Good
____Fair ____Poor
_______________________ _________ _____________
First
MI
Jr/Sr
Have you had any major life changes during the past Year? (such
as a new baby, job change, death of a family member)
Height _______
Weight ______
Age _______
_____Yes
______No
Blood Pressure at last doctor’s visit: ___________
Health Habits
Are you: ( ) Righthanded
( ) Lefthanded
Do you exercise regularly? ________ Yes _______No
If yes, how often and what type of activities?
Cultural / Religious: Any customs or religious beliefs or wishes that might
__________________________________________
affect care? _________________________________________________
Do you use tobacco products? _______ Yes ________ No
Education:
Typed used? _______________________
Highest grade completed (circle one): 1 2 3 4 5 6 7 8 9 10 11 12
If no, have you used tobacco products in the past?
___ Some college/ technical school
________ Yes ______ No Year Quit:_________
___ College school / advance degree
___ Graduate School/Advance Degree
How many days per week do you drink beer, wine, or other
alcoholic beverages, on average? ____________
Employment:
___ Working full-time
___ Working part-time
Family History (indicate whether mother, father, brother/sister,
outside of home
outside of home
aunt/uncle, or grandmother/grandfather had any of the following
___ Working full-time
___ Working part-time
disorders and provide age of onset if known)
from home
from home
___ Homemaker ___ Student ___ Retired
___Unemployed
Heart disease: ______________________________________
Hypertension: ______________________________________
Occupation:______________________________________
Stroke: ____________________________________________
Diabetes: _________________________________________
Who referred you to Physical Therapy:__________________
Cancer:___________________________________________
Other: ____________________________________________
Date of last visit to Referring Physician: _________________
Medications:
Where do you live?
Do you take any prescription medications? ___ Yes ___ No
____Private home
____Private apartment
If yes, please list:
____Rented room
____Hospice
Medication
Dosage
Frequency
____Board and care/assisted living/group home
___________________________________________________
____Homeless(with or without shelter)
___________________________________________________
____Long-term care facility(nursing home)
___________________________________________________
Other:_______________________________________________
_______________________________________________
__________________________________________________
With whom do you live?
__________________________________________________
____Alone
____Spouse only
____Spouse and others
____Child(not spouse)
Patient Provided List __________
____Other relative(s) (not spouse
____Personal care attendant
or children)
PT Initial
____Group setting
Other: ___________________
Allergies:
Does your home have:
Do you use:
Do you have any allergies? ___Yes ___No
If yes, please list: _____________________________________
____Stairs, no railing
____Cane
Do you take any nonprescription medications or supplements?
____Stairs, w/railing
____Walker or rollator
_______ Yes _________No
____Ramps
____Manual Wheelchair
If yes, what?_____________________________________
____Elevator
____Motorized wheelchair
____Uneven Terrain
____Other________________
____Other Obstacles: _______________________
General Health
Therapist Initials: ___________________________
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