Physical Therapy Evaluation
Physician’s Certification
THERAPY NETWORK RESOURCES
Multiple Disciplines:
Yes/No
Referring Agency:____________________________________________
Date:___________________
Patient Name: _______________________________________________________
DOB:___________________
Visit Time: Begin ______________ End ____________  Billable  Non-Billable Supervisory
Visit Type:  Initial Evaluation
HHC Start of Care Date: _____________________ROC Date: ___________________ SN  PT
 Re-evaluation
Diagnosis: _____________________________________________________________________________ Onset Date: _____________
Homebound Status:  falls risk   strength/aerobic capacity   ability to walk without assistance   cognition
 requires assistance to complete general mobility  requires assistance with self care activities
Falls History: __________ falls in last one month; ____________ falls in last 3 months; ___________ total falls in last one year
Precipitating Factors:  improper footwear  environmental hazards  dizziness/vertigo  medication-related  weakness/pain
Past Medical History:  cardiac  diabetes  neurological: __________________________________  OA/RA: ________________
 Other: ______________________________________________________________________________________________________
 Surgeries: ___________________________________________________________________________________________________
KEY
S
Functional Assessment
Strength: 0/5 – 5/5
ROM: Degrees
Shoulder Flexion
Extension
ABD/ADD
IR
ER
Elbow Flexion
Extension
Forearm Pronation
Supination
Wrist Flexion
Extension
Hand Flexion
Extension
Hip Flexion
Extension
ABD/ADD
IR/ER
Knee Flexion
Extension
Ankle Dorsiflexion
Plantarflexion
Inv/Eversion
Neck Flexion
Extension
Trunk Flexion
Extension
STRENGTH
L
R
ROM
L
1. Independent 2. Modif. Ind. 3. SBA/CGA 4. Min A 5. Mod A 6. Max A 7. Dependent 8.Unsafe/Unable
R
Rolls/Scoots in bed
Supine – Sit
Sit - Stand
Transfers/Stand Pivot
W/C mgmt/propulsion
Car transfers
Toilet transfers
Shower/Tub transfers
Standardized Measures/Falls Risk
Functional Reach (FR)
Trial #1____ in. Trial#2 ____in. Trial #3 ___in. (+ at < 6 inches)
One-leg stance Test
Eyes open ____ sec Eyes closed ____ sec
Timed Up & Go
Trial #1 _____ sec Trial # 2 _____ sec AD used ______ (+ at < 14 sec)
______ m /sec
4 M Gait velocity
(+ at < 5 sec.)
(+ at < 0.6 M/sec)
Gait and Assistive Device Assessment
1. Independent 2. Modif I 3. SBA/CGA 4. Min A 5. Mod A 6. Max A 7. Unable/Depend. 8. Unsafe
A. SPC B. SBQC C. LBQC D. hemi-walker E. standard walker F. rolling walker G. 4-wh.walker H. other
Weight-bearing status
 L LE
Assistive Device
Assistance Required
Aerobic Capacity/BORG scale: /20
 Level surfaces  Nat. Terrain  Steps  Ramp
Vital Signs
N/A
 R LE
 Bilateral LE
BP____/____ P______bpm RR_______ O2Sat _____%
Patient on INTERMITTENT / CONTINUOUS OXYGEN @ ______L/minute
If Intermittent □ used □ not used during testing
Additional Standardized Measures
2-minute step test (count R only)
_____ steps □ average □ below average
Pain Assessment: Visual Analog Scale = _____/10 (pre) ______/10 (post)
Location: _____________________________________________________________
Pain Characteristics:  sharp  dull/aching  burning  radiating  other: _____
Medications: ____________________________________________________________
What INCREASES / DECREASES Pain: _____________________________________
Pain Frequency:  occasional  daily  constantly  with movement/activity  night
PLOF: How long ago? ____ months/weeks_
 How long using device (s) _____ months/weeks
Self Care:  Independent  Assistance
Bed Mobility:  Independent  Assistance
Transfers:  Independent  Assistance
Is pain?  acute (within last 60 days)  sub-acute (within last 6 months)  chronic
Ambulation:  Indoor  Steps #____  Rail L/R
___________________________________________________________
 Independent  Assistance Device: ________
0
1
2
3
4
5
6
7
8
9
10
 Outdoor:  Level  uneven/natural terrain  steps# ___
 Rail L/R  Independent  Assistance Device: ________
 IE: History of Current Condition/Reason for Referral:  Re-eval: 60-Day Summary of Care:  Post Hospital Resumption:
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Patient Goal: (what would patient like to do that they are unable to do currently?) ________________________________________________
_________________________________________________________________________________________________________________
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Patient Name: _____________________________________________________
ID #: _____________
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Sensory Systems Assessment:
Visual System
Intact
Impaired Other Sensory Systems
Visual Acuity
Sensation – Cutaneous
Peripheral Vision
Sensation – Proprioception
Depth Perception
Auditory System
Intact
Impaired Additional Comments:
Additional Visual Information: □ Cataracts □ Legal blindness □ Macular Degeneration □ Visual Field Cut/Neglect
□ Other: _______________________Assistive device used(hearing aids etc.): ______________________________________________
Additional Assessment Section:
Orthostatic Hypotension Assessment: Positive
Negative
Motor Control:  Intact  Impaired : Left / Right Upper Extremity / Lower Extremity
Tonal Changes:  Hemiplegia  Hemiparesis  Ataxia  Tremors  Rigidity  Other: _______________________
DME:  wheelchair  Motorized wheelchair  Rolling walker  Standard walker  3 / 4 wheeled walker  with / without seat
 LBQC  SBQC  crutches: ____________________________  SPC  NONE
 Oxygen  Prosthetic / Orthotic: ___________________________________________________________________________
 Other DME Present in home: ______________________________________________________________________________
 DME NEEDS: __________________________________________________________________________________________
Environment:  Safe  Unsafe: See attached form for content.
 Supportive: FAMILY FRIENDS CAREGIVER
 Residing: IN HOME LOCALLY
Availability:  Daily
 As Needed
 Around Work Hours
 Evenings/Nights
Vestibular Assessment:  Central Screens  Hallpike- Dix Testing  Canalith Repositioning Maneuver  Patient education
Findings: (+) / (-)  Left  Right  ______________________ canalithiasis / cupulolithiasis
Standardized Measure of Balance: (see attached score sheets)
Confidence:  Falls Efficacy Scale (FES) score: _____% Actvities-Specific Balance Confidence Scale (ABC) score:______%
□ Berg Balance Test = _____/56
□ Tinetti-POMA: □ Balance = _____/16 □ Gait = _____/12
Safety Awareness:  Intact  Impaired : _______________________________________________________________________________
Balance in Functional Positions:
Functional Position
Stage of Motor Control
Activity Able to Complete
Assistance Required
Unsupported sitting on static surface
□ Stability
□ Controlled Mobility
□ Skill
Unsupported standing on a static
surface
□ Stability
□ Controlled Mobility
□ Skill
□ Maintain position
□ Move within position □ small arc □ large arc
□ Move into/out of position
□ Maintain position with distal segment(s) free
□ UE support
□ UE support
□ External Assist
□ External Assist
□ UE support
□ External Assist
□ Maintain position
□ Move within position □ small arc □ large arc
□ Move into/out of position
□ Maintain position with distal segment(s) free
□ UE support
□ External Assist
□ UE support
□ UE support
□ External Assist
□ External Assist
Gait Assessment:  Modified Gait Abnormality Rating Scale (M-GARS)  Dynamic Gait Index (see attached form)
Abnormal Pattern(s):  Trunk lean (lateral / posterior / anterior)  Pelvic Tilt (posterior / anterior)  Pelvic drop (Trendelenburg)
 Inadequate / Excessive Hip Flexion (Steppage)  Inadequate Hip Extension  Hip Abduction / Adduction  Knee Hyperextension
 Inadequate / Excessive Knee Flex (Buckling)  Foot Flat / Slap  PF Contracture  Excessive INV / EVR  Foot / Toe Drag  Toe Claw
 Other: __________________________________________________________________________________________________________
Physical Therapy Orders:
PT to visit ________ x week for _________ weeks, _______ x week for _________ weeks
AND _______ x week for _________ weeks EFFECTIVE _____/_____/_____:
Problems:  Pain  Impaired Physical Mobility  Joint Replacement  Decreased Strength &/or Endurance  W/C Mobility  ↓ ROM
 Activity Intolerance  Impaired Gait  Risk for Injury  Impaired Transfer Ability  Impaired Functional Mobility  Bed Mobility
Interventions:  PTT01: Physical Therapy to evaluate  PTT02: Therapeutic exercises  PTT03: Instruct in transfers/bed mobility
 PTT04: Gait training + assistive device  PTT05: Establish/instruct in HEP  PTT06: NMES for muscle re-education
 PTT07: Anodyne _______Intensity x _____ mins. to site: _____________________
 PTT08: TENS for pain management
 PTT09: Ultrasound:  Pulsed /  Continuous @ ____w/cm2 x ____mins. to site:_______________
PTT10: Moist heat OR cold/ice x _________mins. to site: _____________  PTT11: Soft tissue massage x _____ mins. to site: ________
 PTT12: Cardiopulmonary education/exercise
 PTT13: Balance training/exercise and falls safety reeducation
 PTT14: Post surgical precautions and limitations  PTT15: Vestibular rehabilitation  PTT16: Prosthetic / Orthotic education/training
 PTT17: Other: _____________________________________________________________________________________________________
 PTT18: Other: _____________________________________________________________________________________________________
May take orders from: (other Physcians)___________________________________________________________________________________
Patient Name: _____________________________________________________
ID #: _____________
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Physical Therapy Goals: (check appropriate boxes and complete phrases
 PTG01: The patient and/or caregiver will be _______________ with home maintenance/exercise program within ________ weeks.
 PTG02: Patient will be ________ % compliant with individualized HEP/maintenance program and completion of provided exercise log
within _______ weeks.
 PTG03: The patient will be safe and ___________ in transfers/bed mobilities to maximize independence within______ weeks.
 PTG04: The patient will increase ____________ strength from ___________ to _____________ to improve _____________________
___________________________________________________within _____________ weeks.
 PTG05: The patient will improve range of motion (ROM) of ___________ from ___________ to ______________ to improve ________
____________________________________________________within ____________ weeks.
 PTG06: The patient will demonstrate a decrease in mobility impairment as evidenced by Timed Up & Go (TUG) score less than/
equal to ________ seconds to improve _______________________________________________within _______________ weeks.
 PTG07: The patient will demonstrate an increase in static balance and decrease risk of falls as evidenced by Functional Reach (FR)
greater than/equal to _______ inches to improve ____________________________________________within __________ weeks.
 PTG08: The patient will demonstrate a reduction in Falls Risk as evidenced by a score < _____ on agency’s multi-factorial Falls Risk
Assessment form within ________ weeks.
 PTG09: The patient will demonstrate an increase in balance and decrease in falls risk as evidenced by Berg Balance Test (BBT) score
greater than/equal to ____/56 to improve _____________________________________________________within _________ weeks.
 PTG10: The patient will demonstrate an increase in balance and decrease in falls risk as evidenced by  POMA  M-GARS  DGI score
greater than/equal to_____/_____ to improve _________________________________________________within _________ weeks.
 PTG11: The patient will demonstrate improvement in gait velocity and a return to functional  household ambulatory status  community
ambulatory status as evidenced by 4M Test score greater than/equal to ___________m/second.
 PTG12: Patient will demonstrate improvement in gait pattern quality with reduction of observed gait impairments throughout
______% of gait cycle and/or ambulation period within _______ weeks.
 PTG13: The patient will be able to ambulate safely and _________________ with _____________ assistive device greater than/equal
to ___________ feet x 6 minutes with improved gait pattern to maximize community mobility independence within _____ weeks.
 PTG14: The patient will demonstrate improved cardiopulmonary/aerobic abilities as evidenced by Borg Perceived Exertion (RPE) rating less
than/equal to _____/10 during/after completion of daily activities within ________ weeks.
 PTG15: The patient will demonstrate improved cardiopulmonary/aerobic abilities as evidenced by 2-Min Step Test (2MST) score greater
than/equal to _____ steps to improve ______________________________________________________ within ________ weeks.
 PTG16: The patient will demonstrate an increase in balance confidence as evidenced by Falls Efficacy Scale (FES)/Activities-Specific
Balance Confidence Scale (ABC) score greater than/equal to _______% to improve ___________________within ________ weeks.
 PTG17: Patient will report a subjective decrease in pain, limiting participation in ADL’s and general mobility of _________% to improve
________________________________________________________within _________________ weeks.
 PTG18: Patient will be __________ with donning/doffing and care of __________________ prosthesis / orthosis within _________ weeks.
 PTG19: Patient will be __________ with post surgical precautions/limitations as evidenced by ability to accurately verbally report/observe
during daily activities and mobility/gait within _______ weeks.
 PTG20: Patient will reduction in pressure ulcer development risk as evidenced by Braden Scale score greater than _____ within ____ weeks.
 PTG21: Other: ______________________________________________________________________________________________________
Other/Narrative Report________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Rehabilitation Potential and Discharge Plan :
Rehab Potential (check ONLY ONE):  Poor  Fair  Good  Excellent
Discharge Plans (check ONLY ONE):  Discharge when goals met to self-care with MD follow-up visits
 Discharge when goals met to family/caregiver with MD follow-up visits  Discharge when goals met to ALF staff with MD follow-up visits
Primary/Referring Physician: _____________________________________ MD Contacted: _____/_____/_____ (date) ____:____ AM /PM
I certify that the above information is true and complete to the best of my knowledge.
 G0151 – PT Services
 G0159 – PT Services, Maintenance Therapy
______________________________________________________
Evaluating Therapist Signature/Title
___________
Date
Patient Signature: _______________________________________
ID #: _______________
_______________________________________________________
Physician Signature
___________
Date