Date of Referral Date of Onset Treatment Diagnosis

                 

Physical Therapy Orders      
History of Present Illness      
     
     
Past Medical History      
     
     
Precautions      
     
Prior Functional Level      
     
Present Functional Level      
Psychosocial History      
Allergies       Medications      
Range of Motion/Strength Orientation Responsiveness
ROM Strength Name Alert
ROM/Strength Place Lethargic
Left Right Left Right
Upper Extremities Time Responds to Verbal Cue
                    Painful Stimuli
Agitation
                                Language Barrier Non-Responsive

                                Specify:       Prior Ambulation
                                      Community
Household
                                Follows Commands
Assist
                                Confused at Times Device      
                                Home Environment Non-Ambulatory

                                Alone Safety Awareness

                                With Help       Poor
Board and Care
Lower Extremities                     Fair
Convalescent/SN
                    Good
            Stairs
Needs Verbal/Tactile Cues
                                Sensation
                                      Pain Status
                                     
                               
                               
                                Trunk Strength/ROM Psychosocial
                                           
Tone
     
     
Coordination       Barriers in Learning Endurance
                 
     
     
Comments       PATIENT IDENTIFICATION
     
     
     
Rehabilitation Therapy
Physical Therapy Evaluation
T3808-T Rev. (09/30/2003) Page 1 of 2
Codes

NT = Not Tested CGA = Contact Guard Assist WBAT = Weight Bear as tolerated Equipment HW = Hemiwalker
NA = Not Applicable Min. A = Minimal Assist PWB = Partial Weight Bearing CR = Crutches SW = Standard Walker
I = Independent Mod. A = Moderate Assist TTWB = Toe Touch Wt. Bearing SPC = Single Point Cane FWW = Front Wheel Walker
S = Supervised Max. A = Maximum Assist NWB = Non-Weight Bearing NBQC= Narrow Base Quad Cane 4WW = Four Wheel Walker
SBA = Stand By Assist U = Unable WBQC= Wide Base Quad Cane WC = Wheelchair
Functional Status
Bed Mobility Assist Transfers Assist Transfers Assist Transfers Assist
Rolling Right       Supine - Sit       Stand - Sit       Toilet      
Rolling Left       Sit - Supine       Bed - WCSit -      
Scooting       Sit - Stand       WC - Bed      
Balance Sitting Standing Gait
Static             Equipment       Distance (Feet)      
Dynamic             Assist       Weight Bearing      
Gait Analysis
     
     
Assessment
Problems Plan of Treatment
Decline in Bed Mobility       Bed Mobility Training
Decline in Transfers       Transfer Training
Decline in Gait       Progressive Gait/Stairs Training
Safety Awareness Deficits       Instructions on Safety
Balance Deficits       Balance Training
ROM/Strength Deficits       Therapeutic Exercises (specify)      
           
           
Other (specify)       Patient/Caregiver/Staff Teaching Program
       Other (specify)      
           
           

Short Term Goals Long Term Goals

Improve Bed Mobility to:       Improve Bed Mobility to:      
Improve Transfers to:       Improve Transfers to:      
Improve Gait/Stairs Mgt. to:       Improve Gait/Stairs Mgt. to:      
Improve Safety Awareness to:       Improve Safety Awareness to:      
Improve ROM/Strength to:       Improve ROM/Strength to:      
Others (specify)       Other (specify)      
           
           
Initiate Patient/Caregiver/Staff Teaching Program Independent in Home Exercise Program; Good Return Demonstration of
All Instructions by Staff/Caregiver

Patient's Goals      

     
     
Rehab Potential       Tentative Discharge Plans: Home Rehab Other      

Frequency/Duration of Treatment      

Comments       PATIENT IDENTIFICATION
     
     
Registered Physical Therapist Date

Physician Approval Date

Rehabilitation Therapy
Physical Therapy Evaluation
T3808-T Rev. (09/30/2003) Page 2 of 2

Physical, Occupational & Speech Therapy Evaluations Guidelines

Form #T3808-T

Procedure:

 Disability specific addendum sheet may be required.

 List additional discipline specific standardized tests performed (i.e., home evaluations,
vestibular testing, etc.) as follows and attach results:
Physical Therapy T3808 in the Comments section at the bottom of page two;
Occupational Therapy T3809 in the Comments section at the bottom of page two;
Speech Therapy T3810 in the Addendum Evaluations section at the bottom.

 Prepared By (Name/Title): signature(s) of the staff member(s) who complete(s)

Summary of Client Progress or Recommendations.

 Initial & Signature/Title Section: (at the bottom) is to be completed by all reviewing
therapists and social workers

 If an addressograph is not available, hand write patient’s name in the Patient Identification
area
T3808-T Rev. (09/30/2003)