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    Book 1

    Uploaded by

    Mariano Lumangkibe
    This document contains an initial evaluation form for a patient seeking physical therapy. It collects information on the patient's medical history, symptoms, functional status, physical examination findings, and the physical therapist's assessment. The evaluation addresses the patient's name, age, diagnosis, symptoms, goals, functional abilities, medical history, social factors, physical examination findings including range of motion and strength testing, and the physical therapist's diagnosis and proposed treatment plan.

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    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd

    Book 1

    Uploaded by

    Mariano Lumangkibe
    22 views10 pages
    This document contains an initial evaluation form for a patient seeking physical therapy. It collects information on the patient's medical history, symptoms, functional status, physical examination findings, and the physical therapist's assessment. The evaluation addresses the patient's name, age, diagnosis, symptoms, goals, functional abilities, medical history, social factors, physical examination findings including range of motion and strength testing, and the physical therapist's diagnosis and proposed treatment plan.

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    Book1

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    This document contains an initial evaluation form for a patient seeking physical therapy. It collects information on the patient's medical history, symptoms, functional status, physical examination findings, and the physical therapist's assessment. The evaluation addresses the patient's name, age, diagnosis, symptoms, goals, functional abilities, medical history, social factors, physical examination findings including range of motion and strength testing, and the physical therapist's diagnosis and proposed treatment plan.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
    22 views10 pages

    Book 1

    Uploaded by

    Mariano Lumangkibe
    This document contains an initial evaluation form for a patient seeking physical therapy. It collects information on the patient's medical history, symptoms, functional status, physical examination findings, and the physical therapist's assessment. The evaluation addresses the patient's name, age, diagnosis, symptoms, goals, functional abilities, medical history, social factors, physical examination findings including range of motion and strength testing, and the physical therapist's diagnosis and proposed treatment plan.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
    of 10

    GENERAL SANTOS DOCTORS’ MEDICAL SCHOOL FOUNDATION, INC.

    Bulaong Subdivision, Barangay West, General Santos City 9500


    Tel No.: (083) 302-3507, Telefax No.: (083) 552-9793

    DEPARTMENT OF PHYSICAL THERAPY


    COMMUNITY BASED REHABILITATION

    INITIAL EVALUATION
    DATE:___________

    Name: Age: Sex: Occupation: Birthday:


    Address: Civil Status: Education:
    Nationality: Language: Handedness:
    Religion: Contact #: Type of Patient:
    Referring MD: Date of Evaluation: Dx:
    S:
    C/C:

    HPI:

    Pt. Goal:

    Prior Level of Fxn:

    Current Level of Fxn:

    Social Hx:

    Employment Status:

    Living Envirionment:
    GENERAL SANTOS DOCTORS’ MEDICAL SCHOOL FOUNDATION, INC.
    Bulaong Subdivision, Barangay West, General Santos City 9500
    Living Envirionment: Tel No.: (083) 302-3507, Telefax No.: (083) 552-9793
    General Health Status:

    Social Health Habits:

    Family Health Hx:


    Disorder Maternal Paternal Patient
    Heart Disease
    Osteoarthritis
    Rheumatoid Arthritis
    Hypertension
    Cancer
    Diabetes Miletus
    Stroke
    Osteoporosis
    Psychological Conditions
    Sig:

    PMHx:

    Other Ancilliary Procedures:

    Meds:

    O:
    Systems Review:
    Cardiovascular System Integumentary System Musculoskeletal System
    Status: Status: Status:
    BP: Integrity: Gross ROM:
    PR: Color: Gross MMT:
    RR: Elasticity: Gross Symmetry:
    T: Ht:
    Wt:
    Neuromuscular System
    Status:
    Balance:
    Motor Fxn:
    Locomotion:
    Bed Mob:
    Transfers:
    Amb:
    Communication:

    Affect:

    Cognition:

    Learning Barriers:

    Learning Style:

    Learning Needs:

    Test and Measures:


    OI:

    Palpation:

    ROM:
    Joint AROM PROM N Diff End-Feel
    A P

    Sig:

    MMT:
    Legend:
    5 full ROM, against gravity, strong resistance
    4+ full ROM, against gravity, near strong resistance
    4 full ROM, against gravity, moderate resistance
    4- full ROM, againts gravity, near moderate resistance
    3+ full ROM, against gravity, slight manual resistance
    3 full ROM, against gravity, no resistance
    3- at least 50% ROM, against gravity, no resistance
    2+ full ROM, gravity minimizied, slight resistance
    2 at least 50% ROM, gravity minimized, no resistance
    1+ less than 50% ROM, gravity minimized, no resistance
    1 no observable motion, palpable muscle contraction, resistance
    0 no observable/palpable contraction
    Facial MMT:

    Sig:

    Postural Ax:
    Anterior Posterior Lateral
    Cephalocaudal Approach
    Head

    Neck

    Shoulder

    Trunk

    Pelvis

    Knees

    Malleolus
    Sig:

    LLD:

    Sig:
    Stump Measurement:
    Landmark:
    Total Length:
    PTB:

    Functional Rating Index


    Legend:
    0 no pain
    1 minimal pain
    2 moderate pain
    3 maximal pain
    4 worst possible pain
    ACTIVITY SCORE
    Pain Intensity
    Sleeping
    Personal Care
    Travel
    Work
    Recreation
    Freq. of Pain
    Lifting
    Walking
    Standing
    TOTAL SCORE: score/40x100=__%
    Sig:

    MBM:
    Segment Landmark 4 in. above 4 in. below

    Sig:

    LGM:

    Sig:
    Sig:

    Special Tests:

    Sensory Ax:

    Neurological Ax:

    Tone Ax:

    Sig:

    Pathologic Reflex:

    DTR:
    Legend
    0 areflexia
    1+ hyporeflexia
    2+ normoreflexia
    3+ hyperreflexia
    4+ clonus
    5+ sustained clonus
    Cranial Nerve Testing:
    Cranial Nerve Stimulus Response
    CN I
    CN II
    CN III
    CN IV
    CN V
    CN VI
    CN VII
    CN VIII
    CN IX
    CN X
    CN XI
    CN XII
    Sig:

    Coordination Ax:

    Sig:

    Gait Analysis:

    A:
    PT Dx:

    PT Prognosis:

    Problem List:
    Impairments:
    Impairments:

    Activity Limitations:

    Participation Restrictions:

    Impairment Goals:

    Activity Limitation Goals:

    Participation Restriction Goals:

    P:
    Stamp & Signature:

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