Physical Therapy Initial Evaluation Form

Physical Therapy Initial Evaluation Form — Form Fields

This healthcare template includes 7 fields. Gather functional history, pain assessment, and treatment goals for new physical therapy patients. Free to customize and use on ZenBuild.

• Patient Full Name (text, required)
• Referring Physician (text, optional)
• Describe your main complaint or reason for seeking physical therapy (long text, required)
• Current pain level at rest (1 = no pain, 5 = severe pain) (rating, required)
• Current pain level during activity (1 = no pain, 5 = severe pain) (rating, required)
• Which functional activities are limited by your condition? (select all that apply) (checkboxes, required) — options: Walking, Climbing stairs, Driving, Reaching overhead, Lifting or carrying, Work-related tasks
• What are your rehabilitation goals? (long text, optional)