Physical Therapy Assessment Form (Page 2 of 3) in pdf

A Step Ahead Physical Therapy

PHYSICAL THERAPY ASSESSMENT

PHYSICAL THERAPY PATIENT/CLIENT MANAGEMENT

Today’s Date: ______________

Name:_____________________________________________

Within the past year have you had any of the

Medical History Form & Medications Reviewed

Please check if you have ever had:

following medical Tests:(Check all that apply)

____ Infectious disease (such

___ Angiogram

___ Mammogram

____ Arthritis

as tuberculosis, hepatitis)

___ Arthroscopy

___ MRI

____ Blood disorders

____ Kidney problems

___ Biopsy

___ Myelogram

____ Broken bones/

____ Low blood sugar/

___ Blood test

___ NCV (nerve conduction

fractures

hypoglycemia

velocity)

____ Cancer

____ Lung problems

___ Bone scan

___ Pap smear

____ Circulation/

____ Multiple sclerosis

___ Bronchoscopy

___ Pulmonary function test

vascular problems

____ Muscular dystrophy

___ CT scan

___ Spinal tap

____ Depression /

____ Osteoporosis

___ Doppler ultrasound

___ Stool test

Psychological problems

___ Echocardiogram

___ Stress test (eg, treadmill,

____ Developmental or

____ Parkinson’s diseases

___ EEG (electroencephalogram)

bicycle)

growth problems

____ Repeated infections

___ EKG (electrocardiogram)

___ Urine tests

____ Diabetes/high

____ Seizures/epilepsy

___ EMG (electromyogram)

___ X-rays

blood sugar

____ Skin diseases

____ Eating or Nutritional Disorders ____ Head injury

Current Limitation (Check all that apply)

____ Stroke

____ Heart problems

___ Difficulty with bed mobility

____ Thyroid problems

____ High blood pressure

___ Difficulty with

transfers (such as moving from bed to chair, from

____ Ulcers/stomach problems

____ Other: ________________

bed to commode)

___ Difficulty walking

For Men:

___ on level surface

___ on stairs

___ on ramps

Have you been diagnosed with prostate disease?

___ on uneven terrain

_____ Yes

_____ No

___ Difficulty with self-care (such as bathing, dressing, eating, toileting)

For Women:

___ Difficulty with home management (such as household chores,

Have you been diagnosed with:

shopping, driving/transportation)

Pelvic inflammatory disease?

___ Difficulty with community and work activities/integration

_____ Yes

_____ No

___ Difficulty work/school

Endometriosis?

___ Difficulty recreation or play activity

_____ Yes

_____ No

Trouble with your period?

History of Current Problem(s)

_____ Yes

_____ No

When did the problem(s) begin? ____/____/____

Complicated pregnancies or deliveries?

What happened?

_____ Yes

_____ No

_____________________________________________________

Pregnant, or think you might be pregnant?

______________________________________________________

_____ Yes

_____ No

____________________________________________________

Have you ever had surgery? ____ Yes

____ No

Have you ever had the problem(s) before?

If yes, please describe, and include dates:

___ Yes

____ No

Month/Year

What did you do for the problem(s)?

_______________________________ ____/______

_________________________________________________

_______________________________ ____/______

_______________________________________________

_______________________________ ____/______

Did the problem(s) get better?

____ Yes ____ No

Within the past year, have you had any of the following symptoms?

About how long did the problem(s) last?

(Check all that apply)

_______________________

___ Bowel problems

___ Hoarseness

___ Chest pain

___ Joint pain or swelling

How are you taking care of the problem(s) now?______________

___ Coordination problems

___ Loss of appetite

________________________________________________

___ Cough

___ Loss of balance

________________________________________________

___ Difficulty sleeping

___ Nausea/vomiting

What makes the problem(s) worse__________________________

___ Difficulty swallowing

___ Pain at night

________________________________________________

___ Difficulty walking

___ Shortness of breath

___ Dizziness or blackouts

___ Urinary problems

What activities are you not able to do now that you could do before

___ Fever/chills/ sweats

___ Vision problems

the problem(s)? (Please be as specific as you can; for instance

___ Headaches

___ Weakness in arms or legs

“Unable to reach over my head”)

___ Hearing problems

___ Weight loss/gain

______________________________________________________

___ Heart palpatations

____________________________________________________

___Other:_______________________________________

Therapist Initials: ___________________________

Physical Therapy Assessment Form Page 2

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