Physical Therapy Patient Evaluation Form – Format and Sample

I have developed this Physical Therapy evaluation form based on what I usually need to know from my patient.  It was designed mainly for sub-acute or inpatient setting,  but it can also be utilized in various other settings such as outpatient and home health.  The purpose of this article is to help other therapists have information quickly available when they need it.  Feel free to add/remove items based on your professional needs.    A downloadable version is attached at the bottom of the post.

Components of Physical Therapy Patient Evaluation Form

The form is divided up into major subsections.  Each one is explained below.

• Demographics

This section generally includes name, DOB, gender, ethnicity, height, weight, etc.. This section will inform you about the orientation and alertness level of your patient (if your patent fills out the form). It also provides you some information vaguely like undernourishment (based on height and weight), some diseases a patient is prone to develop based on age, gender, and ethnicity.

• Past Medical History (PMH): 

This is to find out any medical issues, apart from their current visit with you. It is crucial to know about their health status, any contraindication to treatment, any complications they are prone to develop, etc..

• General health (hearing, vision, etc): 

This talks about any hearing or vision issues your patient has. It also talks about how healthy they see themselves as. You will be surprised by some of the answers!! This is more like their perception of themselves. But it surely serves the purpose of how much adherence you are going to get with home exercises program etc..

• Hospitalization/Surgeries: 

Knowing hospitalization, especially recent ones, will guide you towards any recent issues with your patients. Your physical therapy examination will provide you details but knowing this will give you ideas on what to look for during the examination. This is like information to keep on the back of your mind while performing an evaluation.

• Family History: 

As we know certain conditions are genetic in nature and certain disease travel in families. For example, if a patient comes to you with RA symptoms, you are going to expect some positive family history here.

• Behavioral Health:

This is crucial, especially in this era. Many physical symptoms have a direct connection to how you feel psychologically. The behavioral health will also provide you with information like depression, need for psychotherapy, any addiction, any rehabilitation, etc..

• Medications: 

Knowing the type of medication your patient is taking helps to know the side effects your patients may be facing. It may be why they are visiting you today, unknowingly of course.  For instance, a patient complains of frequent falls and has poor balance and comes to a PT. It may be their medication that affects their balance. And they may be totally unaware of it.

Another example,  long-term use of statin is known to have muscle weakness and muscular pain. Some medications cause dizziness, drowsy and lethargic feeling, blurred vision, etc.. These are issues PT has to know. We have to educate patients regarding these effects caused by their medications and what to do for that.  Now by any means, I am not telling you to tell your patient to stop taking that particular medication. You can educate and guide them to talk with their doctor about any particular side effects they are facing. A PCP should be able to evaluate a situation and make necessary changes.

• Clinical Labs and Tests: 

This will provide you with information on labs and any other diagnostic tests your patient needs to have in the recent past. I like to review my patient’s labs (again, I work in an inpatient facility so it is easier for me to access labs and imaging). I know my patient is going to be more tired if his or her Hb (hemoglobin) is low, or they will c/o muscle soreness with low sodium.

Now, I also know it is crazy to memorize all normal lab values, but get in habit of looking labs for your patients. After some time, you will know what is normal and not.. You will feel confident. With knowledge of labs, your examination will be faster and easier as now you know what to expect generally from that body. That’s all. It is that easy.

• Recent health condition/habit changes: 

This is to know the general health of patients. It also guides us towards their psychological state of being and any memory issues.

• Pain History

History of pain is crucial. It is important if they are coming to you with primary c/o pain. You need to find out the intensity of pain, any aggravating and relieving factors, the onset of pain, time of the pain along with many other factors. It will also help to know if a person faced a similar kind of a pain in the past and how did he recover from it.

Remember, feeling of pain is subjective, and so does the pain classification scales. You need to use your clinical expertise to determine the impact of the pain.

• Social History

A patient’s degree of social support is as important to understand as their physical state.  Research has repeatedly concluded better and successful medical outcomes with good social support and help from family. This will help you to know if your patient is going to get encouragement from family – it may be just to adhere to the HEP you have provided.

This section also aims to identify how active/social the patient is, and what activities they are interested in.    Some of the answers in this section can help you identify more tailored exercise programs for a better outcome.

• Goal for Therapy

What does the patient what to achieve from coming to Physical Therapy?  What motivated them to come for treatment.

I have a patient telling me he is here just because his wife gave him an ultimatum to visit a PT. You are not going to get much motivation and adherence to exercise programs from such patients. Contradictory, I had a 92 years old female telling me she wants to get better so she can sit on Casino chair and play!! I knew she is going to get there as she was already motivated. So what your patient wants to achieve is important for them and for you as their PT.

• Home Environment

This may not apply in all settings, but, can help you understand the day to day life of the patient and evaluate any potential risk factors.

• Additional Information

Intended to capture any special circumstances or other information the patient wishes to share.

Printable Form

 

This is a general history taking form for evaluation.  From here, you need to gather chief complaints and divide your evaluation into Ortho, Neuro, wound, Cardio- Pulmonary, etc… Stay tuned for quick reference guides on those eval formats.

Feel free to leave your thoughts/comments/suggestions in the comments section below.