Home Care Physical Therapy Initial Evaluation
Time IN: ______
Time OUT: ______
Agency: __________________________________________________ Patient Signature: _________________________________________
Patient Name: _____________________________________________________________
Date:_________________
Age: __________
Diagnosis: _________________________________________________________________ Onset: _____________________________________
Post Medical History
 Cardiac
 Respiratory
 NIDMM/IDDM
 Fractures
 CVA
 Falls
 Hypertension
 Other
 Cancer
 Osteoporosis
Prior Level of Function : (I = Independent D = Dependent)
I
I
I
I
D
D
D
D
Community Gait
Limited Community Gait
Household Gait
Limited Household Gait
Precautions :
 WB Status ______________
 THR Precautions
Other
Functional Limitations :
 Amputation
 Dyspnea with Minimal Exertion
 Legally Blind
Living Situation:
Caregiver:
 No Assistive Device
 Used Gaited Walker
 Used Cane
 Used Wheelchair
 IADL and ADL
 IADL Only
 Dependent ADL
 Other Limitations
 Use ______________ with gait
 Laminectomy Precautions
 Hearing
 Contracture
 Speech
 Present
 Absent
 Willing to assist with program
 Ambulation
 Bowel/Bladder
 Endurance
 Able to assist with program
 Unable to assist with program
Home Environment:
 Appropriate
Equipment in Home:
 Walker
 Grab Bars
Vital Signs:
BP _____ / ______ Heart Rate: ________
Mental Status :
 Oriented
 Forgetful
Pain:
Intensity: None
Locations:
1
 Disoriented
2
3
 Use Gait Belt
 Fall Precautions
 Proper Body Mechanics

 Paralysis
 Other(Specify)
_______________________
 Unable to assist with program
 Inappropriate
 Agitated
4
 Cane
 3 in 1 Commode
 Comatose
5
6
 Wheelchair
 Raised Toilet Seat
 Bath/Shower Seat
 Other
Respiration _____________
 Depressed
7
 Lethargic
8
9
 Other_______________
10
Severe
Increases with:
Decreases with:
 Intermittent
Description:
Physical Evaluation:
 Constant
 Dull
 Sharp
A. ROM: Neck/Trunk:
Limitations:
 WNL
 RUE WNL
 LUE WNL
 RLE WNL
 LLE WNL
B. Strength
Limitations:
 WNL
 RUE WNL
 LUE WNL
 RLE WNL
 LLE WNL
C: Neurological:
Paresthesias:
Sensation:
Proprioception:
Tone:
Reflexes:
Other:
D. Posture:



No Abnormality
Kyphosis
Scolliosis



Forward Head
Protracted Shoulders
Leg Length Discrepancy
 Genu Valgum / Varud / Recurvatum
 Ankel Pronation / Supination
 ________________________ Lordosis
E.
Mobility
Home Care Physical Therapy Initial Evaluation
I
SBA
CGA
Min A
Mod
A
Max
A
Unabl
e
Comments
I
SBA
CGA
Min A
Mod
A
Max
A
Unabl
e
Comments
I
SBA
CGA
Min A
Mod
A
Max
A
Unabl
e
Comments
Bed Mobility
Rolling
Scooting
Supine to Sit
Deviations
Transfers
Sit to Stand
Bed to Chair
Toilet
Shower
Other
Deviations
Wheelchair
Other
Deviations
F. Balance
G. Gait:
WB
WBAT
NWB
TTWB
PWB
Assistive Device
Walker
Quad Cane
Hemi Walker
St Cane
Crutches
Other
Assistance
I
SBA
CGA
Min A
Mod A
Max A
Distance
Deviations
Decrease heel toe gait
Decrease reciprocal arm swing
Decrease base support (BOS)
Loss of balance (LOB)
Antalgic gait
Shuffling gait
Waddling
Cadence (Fast/Slow)
Festinating
Other
H. Endurance
I. Other:
Barriers




Stairs indoors with rails
Stairs outdoors without rails
Excessive clutter, inaccessibility
Unsafe bathroom set-up
Rehab Potential:
Goals: (See Plan of Care)
Treatment Plan (Frequency, Duration and Modalities):
Discharge Plans:




Stairs indoors without rails
Wheelchair inaccessibility
Deep pile carpet
Other


Stairs outdoors with rails
 Throw rugs
Inappropriate furniture
Signature/Title: ___________________________________________________________________
Date: __________________