.

PHYSICAL THERAPY EVALUATION FORM

PLAYER INFORMATION DATE_____________________

NAME___________________________________________ CIVIL ID____________________

AGE______ HEIGHT____________ WEIGHT________ KG/LBS

PHONE___________________________________

REHAB INFORMATION
1.CHIEF,COMPLAINT/AILMENT/INJURY______________________________________________
_______________________________
2. DATE OF INJURY________________________ DATE OFSURGERY___________________

3. BRIEFLY DESCRIBE HOW YOU WERE INJURED

_____________________________________________________________________________________
_______
4. HAVE YOU RECEIVED THERAPY FOR THIS CONDITION? YES NO

WHEN?_______________________ HOW MANY VISITS?____________

5. HAS YOUR CONDITION BEEN GETTING: WORSE SAME BETTER 6. ARE YOUR

SYMPTOMS: CONSTANT OR INTERMITTENT-

6.SIDE OF INJURY:_____________ SITE OF INJURY:---------------------------

 BODY CHART (AREA OF SYMPTOMS, BEHAVIOR OF SYMPTOMS, AGGRAVATING
FACTORS, RELIEVING FACTORS, 24 HR PATTERN, VAS SCALE)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_________________________________________________________________________________
______________________________________________

PAIN SCALE: 0 1 2 3 4 5 6 7 8 9 10 (EXCRUCIATING PAIN)

7. WHAT INCREASES/MAKES YOUR CONDITION WORSE? (MARK ALL THAT APPLY)

BENDING MOVEMENT REST SNEEZE SITTING STANDING
STAIRS DEEP BREATH RISING WALKING COUGH
PROLONGED POSITIONING LYING WORSE IN AM WORSE IN PM
WORSE AS DAY PROGRESSES
Musculoskeletal patients

Observation (general and local, including gait and posture)

_____________________________________________________________________________________
_____________________________________________________________________________________
_________________________________________________

Passive Movement
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________

Active movements
_____________________________________________________________________________________
_____________________________________________________________________________________
_________________________________________________
_________________________________________________________________________

Resisted isometrics
_____________________________________________________________________________________
_____________________________________________________________________________________
_________________________________________________

Accessory movements (joint glides)

_____________________________________________________________________________________
_____________________________________________________________________________________
_________________________________________________

Muscle length tests (if needed)

_____________________________________________________________________________________
_____________________________________________________________________________________
_________________________________________________

Muscle strength tests (if needed)

_____________________________________________________________________________________
_____________________________________________________________________________________
_________________________________________________

Neurodynamic testing (if needed)

_____________________________________________________________________________________
_____________________________________________________________________________________
_________________________________________________
Palpation
_____________________________________________________________________________________
_____________________________________________________________________________________
_________________________________________________

Special tests (specific to the joint or structure suspected in the subjective assessment)
_____________________________________________________________________________________
_____________________________________________________________________________________
_________________________________________________

Impression
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_________________________

Management Plan
 DAILY EVALUATION CHART

DATE OF
VISIT TREATMENTS GIVEN IMPROVEMENT OF THE PLAYER