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Click ‘Get Form’ to open the physical therapy evaluation form in the editor.
Begin by entering your name and the date at the top of the form. This information is essential for identifying your evaluation.
For question one, circle a number that represents your least pain and another for your most pain. This helps your therapist understand your pain levels.
In section two, list three activities that exacerbate your symptoms. Be specific to provide clear insights into your challenges.
Next, indicate any positions or activities that alleviate your pain. This information is crucial for tailoring your treatment plan.
In section four, note any improvements you've experienced since starting therapy, such as better sleep or increased activity levels.
List any medications you have stopped or reduced since your last evaluation in section five, and mention any new medications in section six.
Use the shading tool to mark areas of pain on the diagram provided. Darker shading indicates greater discomfort.
Finally, reflect on your overall improvement percentage and share insights about your home self-care/exercise program in the designated area.

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