Physical Therapy Evaluation Guide
Middle School, High School
Name:
Parent:
Teacher:
Physical Therapist:
School District:
Birthdate:
Phone:
Building:
Date Consent Received:
Part I: Record Review
Social History (Parents/guardian, siblings, number of stairs to apartment/house, accessibility of home, involvement with outside agencies) :
Medical/Surgical History:
Equipment (Wheelchair, Orthoses, Assistive Devices):
Strengths/Weaknesses (Student, Teacher, Parent):
Students Likes/Dislikes:
Teacher/Parent Concerns about Student’s Participation in School Environment:
1
Part II: Interviews
Person(s) Interviewed:
Ares of Physical Performance
Date(s):
Summary of performance within the educational program and activities
Activities of Daily Living
(Self-Help and Living Skills)
Education
Work
Play & Leisure
Social Participation
Person(s) Interviewed:
Date(s):
Establishing the Concern: Document the concerns and interventions that currently exist.
1. What is your concern and how does this impact the child’s performance?
2. What have you tried? What is the outcome?
3. How are typical peers performing in this area? (Gather source of information)
4. Describe some of the child’s strengths and preferences in this area.
2
Part III: Observations
Setting(s) Observed:
Date(s):
A. School Mobility:
Student’s Primary Means of Mobility:
Level of Assistance: I=Independent, A=Needs Assistance to Perform, D=Dependent, NA=Not Applicable
Activity:
Level of
Assistance:
Comments:
Opens door to classroom, hallway,
and/or stairwell from either side of
door
Pushes/pulls open door while holding
jacket or book in opposite hand
Moves from one area of school to
another in time allotted between
classes
Knows how to reach any area in
school
Demonstrates safety awareness
during transitions
Maneuvers through crowded hallways
or stairwells (avoiding
objects/students, maintaining balance)
Attends to adult instructions during
transitions
Ascends stairs (# of flights:___ )
Alone or With Classmates
Describe
Exits building/moves to safe area
during fire/tornado drill in appropriate
time
Uses elevator appropriately
B. Classroom/Locker Activities:
Level of Assistance: I=Independent, A=Needs Assistance to Perform, D=Dependent, NA=Not Applicable
Activity:
Level of
Assistance:
Comments:
Dons/doffs coat/book bag
3
Locks/unlocks locker
Removes items from/places items in
locker
Moves in classroom avoiding
furniture/classmates
Moves to/from desk/standing
Sits at desk with adequate posture to
complete classroom activities
Copies from blackboard
Raises hand to participate
Follows teacher’s instructions
Receives papers from and passes
paper to classmates
Able to reach item on high shelf
Able to retrieve item from floor
Retrieves item from floor/under desk
while sitting
Moves to/from wheelchair/classroom
chair
C. Community Mobility and Transportation:
Level of Assistance: I=Independent, A=Needs Assistance to Perform, D=Dependent, NA=Not Applicable
Activity:
Level of
Assistance:
Comments:
Negotiates ramp to enter/leave school
Moves along sidewalk
4
Negotiates curbs
Negotiates crowded sidewalk avoiding
other pedestrians/objects
Recognizes and avoids hazards
Obeys signals when crossing street
Looks both ways before crossing
Crosses street in allotted time
Understands and obeys street signs
Can articulate how to to/from
home/school
Is able to use bus independently
D. Mealtime:
Level of Assistance: I=Independent, A=Needs Assistance to Perform, D=Dependent, NA=Not Applicable
Activity:
Level of
Assistance:
Comments:
Able to negotiate lunchroom avoiding
peers/furniture
Retrieves food items from
distributor/places food items on tray
Carries tray to table without spilling
/dropping foot items
Opens milk/juice, condiments, utensils,
containers
Eats lunch without spilling/choking
Keeps hands, face, clothing clean
Interacts with peers appropriately
5
Cleans up appropriately
Recognizes and avoids hazards
Moves to/from wheelchair/bench
E. Activities of Daily Living: Toileting, Hygiene
Level of Assistance: I=Independent, A=Needs Assistance to Perform, D=Dependent, NA=Not Applicable
Activity:
Level of
Comments:
Assistance:
Recognizes and indicates need to use
bathroom in a timely manner
Moves to/from bathroom/classroom
Enters/exits stall
Locks/unlocks stall door
Manages clothing and zippers
Sits on toilet with stability
Cleans self
Flushes toilet
Washes and dries hands
Manages catheterization
Avoids accidents
Maintains good hygiene (parent,
teacher, student report)
6
Moves to/from wheelchair/toilet
F. Gym Performance and Preparation:
Level of Assistance: I=Independent, A=Needs assistance to perform, D=Dependent, NA=Not applicable
Activity:
Level of
Assistance:
Comments:
Changes into PE attire in allotted time
Participates in activities with
classmates
Follows rules of sport/game
Takes turns appropriately
Demonstrates good sportsmanship
G. Pre-Vocational Skills:
**According to the IDEA legislation, the IEP that will be in effect when the student is 16 years of age must include a transition plan. The
transition plan must include appropriate measureable postsecondary goals based upon age-appropriate transition assessments related
to training, education, employment, and where appropriate, independent living skills. This section of the evaluation may be used to
assist the therapist in completing the transition plan.
What vocational interests does the student have?
What skills are required for these activities?
Which of these skills does the student currently perform independently?
Which of these skills does the student currently require assistance to perform?
7
Part IV: Tests/Assessments
A. Standardized Tests/Measure
Tests/Tools Used
Date Administered
Results
B. Gross Motor Assessment
Range of Motion/Strength Assessment:
AROM
PROM
Manual Muscle Testing (out of 5)
Shoulder:
Flexion (0-180°)
Abduction (0-180°)
Extension (0-60°)
Internal Rotation (0-70°)
External Rotation (0-90°)
L:
L:
L:
L:
L:
R:
R:
R:
R:
R:
L:
L:
L:
L:
L:
R:
R:
R:
R:
R:
L:
L:
L:
L:
L:
R:
R:
R:
R:
R:
R:
R:
R:
R:
L:
L:
L:
L:
R:
R:
R:
R:
R:
R:
R:
R:
R:
L:
L:
L:
L:
L:
R:
R:
R:
R:
R:
R:
R:
L:
L:
R:
R:
R:
R:
R:
R:
L:
L:
L:
L:
R:
R:
R:
R:
R:
R:
L:
L:
R:
R:
R:
R:
Hold curl-up for sec
Hold superman for sec
L:
R:
L:
R:
Elbow:
Flexion (0-150°)
Extension (150-0°)
Pronation (0-80°)
Supination (0-80°)
L:
L:
L:
L:
R:
R:
R:
R:
L:
L:
L:
L:
Hip:
Flexion (0-45°)
Abduction (0-45°)
Extension (0-30°)
Internal Rotation (0-45°)
External Rotation (0-45°)
L:
L:
L:
L:
L:
R:
R:
R:
R:
R:
L:
L:
L:
L:
L:
Knee:
Flexion (0-135°)
Extension (135-0°)
L:
L:
R:
R:
Plantarflexion (0-50°)
Dorsiflexion (0-20°)
Inversion
Eversion
L:
L:
L:
L:
R:
R:
R:
R:
L:
L:
Ankle:
L:
L:
L:
L:
Head/Neck:
Flexion (0-45°)
Extension (0-45°)
Rotation (0-60°)
Lateral Flexion (0-45°)
L:
L:
R:
R:
L:
L:
Trunk:
Flexion
Extension
Rotation (0-45°)
Side bending (0-35°)
L:
L:
R:
R:
L:
L:
8
Tone: Normal, increased, decreased
Postural observation/assessment: in sitting on all surfaces and standing
Gait analysis with/without assistive devices/orthoses: Note any significant deviations
Balance:
Time standing on one foot with arms out to side:
Time standing on one foot with hands on hips:
Distance walked heel-toe with arms out to sides/hands on hips:
Timed Up and Go:
Distance of forward reach in sitting, standing:
Distance of sideways reach in sitting, standing:
R:
R:
L:
L:
Coordination:
Walk a figure 8 pattern:
Number of jumping jacks completed correctly:
Finger to nose test:
Finger to thumb test:
Protective Extension: present, timely delayed
Forward:
Sideways:
Backward:
Part V: Problem Analysis
Complete this form using the data you have gathered.
Supports
Barriers/Limitations
Instruction:
What strategies need to be used in teaching?
Curriculum:
What does child need to learn?
Environment:
What accommodations, program modification,
and/or assistive technology are needed for the
child to learn?
Learner:
What characteristics of the child support or
interfere with learning?
9