Maya Lin

MRN: 10029384 | DOB: 09/12/2005 | Precautions: WBAT Left LE

Physical Therapy Initial Evaluation

Encounter & Identifying Data

Patient Name:

Eval Date:

Onset Date:

Primary Diagnosis / ICD-10:

Age:

Physician Order / Reason for Referral:

Proposed Plan of Care (Interventions)

Bed Mobility Training Transfer Training Gait/Locomotion Training Therapeutic Exercises Neuromuscular Re-ed Manual Therapy Home Exercise Program Balance Retraining Patient/Family Education

Precautions / Contraindications:

History

History of Present Illness (HPI)

Previous Medical/Surgical History:

Prior Level of Function (PLOF) & Adaptive Equipment:

Home Environment / Social History:

Patient's Personal Goals for Therapy:

Diagnostics & Radiology

Radiology Report:

Objective: Observations & Impairments

Pain (0-10):

Cognition / Mental Status:

Sensation / Proprioception:

Motor / Coordination:

AROM / PROM & MMT (Strength)

Joint/Region	AROM/PROM	MMT (0-5)
Shoulder/Elbow
Hip/Knee
Ankle/Foot
Trunk/Spine

Functional Mobility Status

Bed Mobility (Supine to Sit):

Sit to Stand:

Transfers (Bed to Chair/WC):

Assistive Device Used:

Gait / Locomotion

Distance & Assist Level:

Weightbearing & Deviations:

Evaluation / Assessment

Clinical Impression & Summary:

Short Term Goals (Target: )

1. Bed Mobility

2. Transfers

3. Ambulation Distance

4. ROM / Strength

5. Pain Reduction

6. HEP & Precautions

Prognosis & Disposition

Rehab Potential to meet goals:

Frequency & Duration:

Recommended D/C Disposition:

Evaluating Physical Therapist Signature: