Physical Therapy Evaluation Form
This evaluation form assesses progression of patient’s health both physically and mentally. It enables the therapist to access medical history of his patient, development, medical progress and other observations.
Name of therapist: _________________________________
Name of the patient: ___________________________________
A) Please answer YES or No to the questions in the section below:
1. Have you experienced any major changes for the past year? ______
2. Have you undergone any surgery? _____________
Exercises
3. How regularly do you exercise?
a) Thrice Daily____ b) Twice daily ______ c) Daily_______ d) Severally a week____
Health Habits (Answer yes or No to these questions
4. Do you take any alcohol?
Yes ____ No ____
5. How often do you consume alcohol?
Occasionally _____ regularly _______ heavily_______ Don’t drink ______
6. Are you a chain smoker?
Yes ______ No _______
If No, have you ever smoked in the past? Yes____ No ____
Medication
Has any medicine been prescribed?
Yes ____ No _____
B) Current difficulties (Choose relevant answer)
- Walking problem ______________
- Difficult to self-care ______________
- Tiredness ______________
- Difficulty in working ______________
General health observation
Please rate your health (check where appropriate):
Excellent ___ Good ___ Fair ____ Poor__
……………………………………………………………
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