Subjective

History of present condition:

Prior level of function:

Patient-stated goals:

Aggravating and easing factors:

Pain Score

On a scale of 0 to 10, with 0 being no pain and 10 being the worst pain imaginable, how would you rate your pain right now?

012345678910

Pain context

Body site

Search Body site

Laterality

Select laterality...

Pain context

Current

Related condition

Search Related condition

Status

Active

Notes

Document quality, relief factors, and aggravating factors...

Medical History & Precautions

Relevant medical history:

Red flags / precautions screened (check if present):

Unexplained weight loss or night pain

Bowel or bladder changes / saddle anesthesia

Cardiopulmonary symptoms with activity

Recent fall or trauma

Fall risk identified

Objective

Blood Pressure

Systolic · mmHg

Diastolic · mmHg

Heart rate · bpm

Anthropometrics

Weight · kg

KG LB

Height · cm

CM FT/IN

Temperature · °C

°C °F

Notes

Posture and observation:

Range of Motion

Joint / Motion	Left	Right	Notes
Cervical / trunk
Shoulder
Hip
Knee
Ankle

Manual Muscle Test (0–5)

Muscle group	Left	Right
Proximal
Mid
Distal

Special tests:

Palpation findings:

Neurological screen:

Gait and balance:

Functional outcome measures:

Assessment

Diagnosis Search

Diagnosis

Coding Details

Status

Active

Severity

Select severity...

Onset Date

YYYY-MM-DD

Resolved Date

YYYY-MM-DD

Physical therapy clinical impression:

Rehabilitation potential and prognosis:

Plan

Frequency and duration:

Planned interventions (check all that apply):

Therapeutic exercise

Neuromuscular re-education

Manual therapy

Gait / balance training

Modalities for pain control

Patient education / activity modification

Home exercise program issued

Goals

Goal	Baseline	Target	Timeframe
Short-term goal 1
Short-term goal 2
Long-term goal 1
Long-term goal 2

Skilled need and follow-up:

Physical Therapy Initial Evaluation

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