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

Physical Therapy Assessment Form Page 3

A Step Ahead Physical Therapy

PHYSICAL THERAPY ASSESSMENT

PHYSICAL THERAPY PATIENT/CLIENT MANAGEMENT

Today’s Date: ______________

Name:_____________________________________________

What are your goals for physical therapy? __________________

___________________________________________________

Are you seeing anyone else for the problem? (Check all that apply.)

__Acupuncturist

__ Occupational therapist

__ Cardiologist

__ Orthopedist

__ Chiropractor

__ Osteopath

__ Dentist

__ Pediatrician

__ Family practitioner

__ Podiatrist

__ Internist

__ Primary care physician

__ Massage therapist

__ Rheumatologist

__ Neurologist

__ Other: ________________

__ Obstetrician/Gynecologist __ Speech Therapist

It is important that we have a measure of your pain. Please rate the

level of your pain on the following scale.

At present: 0 1 2 3 4 5 6 7 8 9 10

At best:

0 1 2 3 4 5 6 7 8 9 10

At worst: 0 1 2 3

4 5 6 7 8 9 10

(no pain)

(moderate

(extreme

pain)

agony)

Please indicate painful areas by shading these models.

Which of these words describe your pain? (Circle all that apply)

Sharp Dull Burning Aching Tingling

Numb Constant Variable Radiating (moves)

Therapist Initials: ___________________________

Physical Therapy Assessment Form Page 3