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Patient ID#:
Name:
a
Last
First
LIVING ENVIRONMENT
State
Month
18
Jr/Sr
Date of Birth:
Sex:
Are you:
Type of Insurance:
b
Male
a
Day
Zip
Year
10
City
MI
16
Female
Right-handed
a
Workers Comp
Left-handed
Insurer ______________________________
c Medicare d Self-pay e Other
Race:
8 Ethnicity:
a American Indian
a Hispanic or
or Alaska Native
Latino
b Asian
b Not Hispanic
c Black or African
or Latino
American
d Hispanic or
Latino
e Native Hawaiian or
Other Pacific Islander
f White
Education:
a Highest grade completed (Circle one): 1
b Some college / technical school
c College graduate
d Graduate school / advanced degree
Language:
a English
understood
b Interpreter
needed
c Language you
speak most
often:
____________
19
20
SOCIAL/HEALTH HABITS
a Smoking
(1) Currently smoke tobacco? (a) Yes
1.
Cigarettes:
2.
Cigars/Pipes:
2 3 4 5 6 7 8 9 10 11 12
(b)
(2)
12
13
14
No
Employment/Work (Job/School/Play)
a Working full-time
c Working full-time
outside of home
from home
b Working part-time
d Working part-time
outside of home
from home
e Homemaker f Student g Retired h Unemployed
Occupation: ___________________________________
(a)
# per day __
(b)
No
21
Yes
Smoked in past?
No
b Alcohol
(1) How
________________________________________________________
Do you use:
Cane
Walker or rollator
Manual wheelchair
Motorized wheelchair
Glasses, hearing aids
Other: _____________
___________________
___________________
_________________________________________________
SOCIAL HISTORY
11 Cultural/Religious: Any customs or religious beliefs or wishes that
might affect care?
_________________________________________________________
15
17
a
b
c
d
e
f
Outpatient History
Exercise
Do you exercise beyond normal daily activities and chores?
(a) Yes Describe the exercise: ______________________
1. On average, how many days per week
do you exercise or do physical activity? _______
2. For how many minutes, on an average day? ____
(b) No
American Physical Therapy Association 1999; revised September 2000, January 2002, June 2003
MEDICAL/SURGICAL HISTORY
a Please check if you have ever had:
(1) Arthritis
(13) Multiple sclerosis
(2) Broken bones/
(14) Muscular dystrophy
fractures
(15) Parkinson disease
(3) Osteoporosis
(16) Seizures/epilepsy
(4) Blood disorders
(17) Allergies
(5) Circulation/vascular
(18) Developmental or growth
problems
problems
(6) Heart problems
(19) Thyroid problems
(7) High blood
(20) Cancer
pressure
(21) Infectious disease
(eg, tuberculosis, hepatitis)
(8) Lung problems
(22) Kidney problems
(9) Stroke
(23) Repeated infections
(10) Diabetes/
(24) Ulcers/stomach problems
high blood sugar
(25) Skin diseases
(11) Low blood sugar/
(26) Depression
hypoglycemia
(27) Other:_________________
(12) Head injury
b Within the past year, have you had any of the following
symptoms? (Check all that apply)
22
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
c
Chest pain
Heart palpitations
Cough
Hoarseness
Shortness of breath
Dizziness or blackouts
Coordination problems
Weakness in arms or legs
Loss of balance
Difficulty walking
Joint pain or swelling
Pain at night
(2)
now? ____________
______________________________________________________
f What makes the problem(s) better? ________________________
______________________________________________________
g What makes the problem(s) worse? ______________________
______________________________________________________
______________________________________________________
h What are your goals for physical therapy? __________________
______________________________________________________
i Are you seeing anyone else for the problem(s)? (Check all that apply)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
24
25
MEDICATIONS
a Do you take any prescription medications? (1) Yes (2) No
If yes, please list: ______________________________________
______________________________________________________
b Do you take any nonprescription medications?
(Check all that apply)
No
Month Year
_________________________
_________________________
_________________________
For men only: d Have you been diagnosed with prostate disease?
(1) Yes (2) No
Complicated pregnancies
or deliveries?
(1) Yes (2) No
i Pregnant, or think you
might be pregnant?
(1) Yes (2) No
j Other gynecological or
obstetrical difficulties?
(1) Yes (2) No
If yes, please describe:
_______________________
CURRENT CONDITION(S)/CHIEF COMPLAINT(S)
a Describe the problem(s) for which you seek physical therapy:
______________________________________________________
______________________________________________________
Month Year
(1)
(2)
(3)
______________________________________________________
Have you ever had the problem(s) before?
(1) Yes
(a) What did you do for the problem(s)? ____________
_____________________________________________
(b) Did the problem(s) get better?
1. Yes 2. No
(c) About how long did the problem(s) last? __________
(2) No
Acupuncturist
(10) Occupational therapist
Cardiologist
(11) Orthopedist
Chiropractor
(12) Osteopath
Dentist
(13) Pediatrician
Family practitioner
(14) Podiatrist
Internist
(15) Primary care physician
Massage therapist
(16) Rheumatologist
Neurologist
Other: ____________________
Obstetrician/gynecologist
Advil/Aleve
Antacids
Ibuprofen/
Naproxen
Antihistamines
Aspirin
(6)
(7)
(8)
(9)
Decongestants
Herbal supplements
Tylenol
Other: ________________
________________________
________________________
c Have you taken any medications previously for the
condition for which you are seeing the physical therapist?
(1) Yes (2) No
If yes, please list:
____________________________________
(4)
(5)
26
OTHER CLINICAL TESTS Within the past year, have you had any
of the following tests? (Check all that apply)
m Mammogram
a Angiogram
b Arthroscopy
n MRI
c Biopsy
o Myelogram
d Blood tests
p NCV (nerve conduction velocity)
e Bone scan
q Pap smear
f Bronchoscopy
r Pulmonary function test
g CT scan
s Spinal tap
h Doppler ultrasound
t Stool tests
i Echocardiogram
u Stress test (eg, treadmill, bicycle)
j EEG (electroencephalogram)
v Urine tests
w X-rays
k EKG (electrocardiogram)
x Other:________________
l EMG (electromyogram)
American Physical Therapy Association 1999; revised September 2000, January 2002, June 2003
Systems Review
Not
Impaired
Impaired
Not
Impaired
Impaired
MUSCULOSKELETAL SYSTEM
Gross Range of Motion
Edema: ________________________________
Gross Strength
Gross Symmetry
Standing: ____________________________
Sitting: ______________________________
Activity specific:______________________
Gait
Locomotion
Transfers
Transitions
CARDIOVASCULAR/PULMONARY SYSTEM
Blood pressure: ________________________
INTEGUMENTARY SYSTEM
Integrity
Pliability (texture):____________________
Presence of scar formation: ____________
Skin color: __________________________
Skin integrity: ________________________
Other: ________________________________
Height ______________________
Weight ______________________
NEUROMUSCULAR SYSTEM
Gross Coordinated Movements
Balance
Orientation x 3 (person/place/time)
Emotional/behavioral responses
Learning barriers:
None
Vision
Hearing
Unable to read
Unable to understand what is read
Language/needs interpreter
Other: ____________________________________________
How does patient/client best learn?
Pictures
Education needs:
Disease process
Safety
Use of devices/equipment
Activities of daily living
Exercise program
Other: ______________________________________________
American Physical Therapy Association 1999; revised September 2000, January 2002, June 2003
Systems Review
Aerobic Capacity/Endurance
Anthropometric Characteristics
Arousal,Attention, and Cognition
Assistive and Adaptive Devices
Circulation (Arterial,Venous, Lymphatic)
Cranial and Peripheral Nerve Integrity
Environmental, Home, and Work (Job/School/Play) Barriers
Ergonomics and Body Mechanics
Gait, Locomotion, and Balance
Integumentary Integrity
Joint Integrity and Mobility
Motor Function (Motor Control and Motor Learning)
Muscle Performance (Including Strength, Power, and Endurance)
14
15
16
17
18
19
20
21
NOTES:
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American Physical Therapy Association 1999; revised September 2000, January 2002, June 2003
Evaluation
PREFERRED PHYSICAL THERAPIST PRACTICE PATTERNSSM
DIAGNOSIS:
Musculoskeletal Patterns
A: Primary Prevention/Risk Reduction for Skeletal
Demineralization
B: Impaired Posture
C: Impaired Muscle Performance
D: Impaired Joint Mobility, Motor Function, Muscle Performance,
and Range of Motion Associated With Connective Tissue
Dysfunction
E: Impaired Joint Mobility, Motor Function, Muscle Performance,
and Range of Motion Associated With Localized Inflammation
F: Impaired Joint Mobility, Motor Function, Muscle Performance,
Range of Motion, and Reflex Integrity Associated With Spinal
Disorders
G: Impaired Joint Mobility, Muscle Performance, and Range of
Motion Associated With Fracture
H: Impaired Joint Mobility, Motor Function, Muscle Performance,
and Range of Motion Associated With Joint Arthroplasty
I: Impaired Joint Mobility, Motor Function, Muscle Performance,
and Range of Motion Associated With Bony or Soft Tissue
Surgery
J: Impaired Motor Function, Muscle Performance, Range of
Motion, Gait, Locomotion, and Balance Associated With
Amputation
Neuromuscular Patterns
A: Primary Prevention/Risk Reduction for Loss of
Balance and Falling
B: Impaired Neuromotor Development
C: Impaired Motor Function and Sensory Integrity Associated
With Nonprogressive Disorders of the Central Nervous
SystemCongenital Origin or Acquired in Infancy or
Childhood
D: Impaired Motor Function and Sensory Integrity Associated
With Nonprogressive Disorders of the Central Nervous
SystemAcquired in Adolescence or Adulthood
E: Impaired Motor Function and Sensory Integrity Associated
With Progressive Disorders of the Central Nervous System
F: Impaired Peripheral Nerve Integrity and Muscle Performance
Associated With Peripheral Nerve Injury
G: Impaired Motor Function and Sensory Integrity Associated
With Acute or Chronic Polyneuropathies
H: Impaired Motor Function, Peripheral Nerve Integrity, and
Sensory Integrity Associated With Nonprogressive Disorders
of the Spinal Cord
I: Impaired Arousal, Range of Motion, and Motor Control
Associated With Coma, Near Coma, or Vegetative State
Cardiovascular/Pulmonary Patterns
A: Primary Prevention/Risk Reduction for
Cardiovascular/Pulmonary Disorders
B: Impaired Aerobic Capacity/Endurance Associated With
Deconditioning
C: Impaired Ventilation, Respiration/Gas Exchange, and Aerobic
Capacity/Endurance Associated With Airway Clearance
Dysfunction
D: Impaired Aerobic Capacity/Endurance Associated With
Cardiovascular Pump Dysfunction or Failure
E: Impaired Ventilation and Respiration/Gas Exchange
Associated With Ventilatory Pump Dysfunction or Failure
F: Impaired Ventilation and Respiration/Gas Exchange
Associated With Respiratory Failure
G: Impaired Ventilation, Respiration/Gas Exchange, and
Aerobic Capacity/Endurance Associated With
Respiratory Failure in the Neonate
H: Impaired Circulation and Anthropometric Dimensions
Associated With Lymphatic System Disorders
Integumentary Patterns
A: Primary Prevention/Risk Reduction for Integumentary
Disorders
B: Impaired Integumentary Integrity Associated With Superficial
Skin Involvement
C: Impaired Integumentary Integrity Associated With PartialThickness Skin Involvement and Scar Formation
D: Impaired Integumentary Integrity Associated With FullThickness Skin Involvement and Scar Formation
E: Impaired Integumentary Integrity Associated With Skin
Involvement Extending Into Fascia, Muscle, or Bone and Scar
Formation
PROGNOSIS: ____________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
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American Physical Therapy Association 1999; revised September 2000, January 2002, June 2003
Evaluation
Plan of Care
__________________________________________________________________________________________
Frequency of Visits/Duration
of Episode of Care:
________________________
__________________________________________________________________________________________
________________________
__________________________________________________________________________________________
________________________
Interventions: ______________________________________________________________________________
__________________________________________________________________________________________
Education (including safety, exercise, and disease information): __________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Who was educated? Patient/client Family (name and relationship): ________________________________________________________
How did patient/family demonstrate learning:
Patient/client verbalized understanding
Family/significant other verbalized understanding
Patient/client demonstrated correctly
Demonstration was unsuccessful (describe): ____________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Discharge Plan: __________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
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American Physical Therapy Association 1999; revised September 2000, January 2002, June 2003
Plan of Care