PHYSICAL THERAPY EVALUATION
HOME HEALTH THERAPY SOLUTIONS
AGENCY REPRESENTING:
Please Select
Grapevine Home Health
Bright Sky Home Health
Advent Home Health
A C Home Health
In Home Health Care
PATIENT NAME:
THERAPIST NAME:
PATIENT ID:
SOC Date
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Month
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Day
Year
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Date
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Month
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Day
Year
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Time In
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10
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12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Time Out
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5
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10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
REASON FOR EVALUATION:
OTHER DISCIPLINES INVOLVED:
SN
OT
ST
MSW
Aide
HOMEBOUND STATUS
Needs assistance for all activities
Unable to safely leave home unassisted
Dependent upon adaptive deviice(s)
Residual weakness
Requires assistance to ambulate
Severe SOB, SOB upon exertion
Medical restrictions
Confusion, unable to go out of home alone
MEDICAL HISTORY
Hypertension
Cardiac
Diabetes
Respiratory
Osteoporosis
Fractures
Cancer
Infection
Immunosuppressed
Open wound
Falls with injufy
Falls without injury
Other
HOME SAFETY BARRIERS
Clutter
Throw rugs
Bath bench / equipment
Needs grab bar
Needs railings
Steps
Other
BEHAVIORAL / MENTAL STATUS
Alert
Oriented
Cooperative
Confused
Memory deficits
Impaired judgement
Other
LIVING SITUATION
Capable
Able
Willing caregiver available
Limited caregiver support
No caregiver available
VITAL SIGNS / CURRENT STATUS
TAKEN
Please Select
Before Exercises
During Exercises
After Exercises
Position
Please Select
Laying
Sitting
Standing
BLOOD PRESSURE
PULSE
RESPIRATIONS
TEMPERATURE
02 SATS
OXYGEN (LITERS):
PAIN
Please Select
0
1
2
3
4
5
6
7
8
9
10
Location:
Duration:
Aggravating Facrtors
Relief measures:
Impact on Therapy POC
Skin
Edema
Vision
Sensation
Communication
Hearing
Posture
Endurance
THERAPY INTERVENTIONS - INSTRUCTIONS
Establish/upgrade home exercise program
Patient/Family education
Transfer training
Teach safe effective use of adaptive/AD
Gait training
Balance training
Pulmonary Physical Therapy
TENS
Therapeutic exercises
Ultrasound
Electrotherapy
Prosthetic training
Muscle re-education
Cardiopulmonary PT
Wheelchair mobility training
Pain Management
Teach hip safety precautions
CPM (specify)
Teach bed mobility skills
Functional mobility training
Teach safe stair climbing skills
Pulse oxymetry PRN
Other
FUNCTIONAL STATUS
ROM & MMT: (B) UE/LE WFL AND GROSSLY GRADED 4-5/5 (Except Listed Here}
PRIOR LEVEL OF FUNCTION
Assistance
Assistive Devices / Comments
Bed Mob Roll / Turn
Bed Mob Sit / Supine
Scoot / Bridge
Transfers Sit / Stand
Transfers Bed / WheelChair
Toilet
Floor
Auto
Balance Static Sitting
Balance Dynamic Sitting
Balance Static Standing
Balance Dynamic Standing
W/C Propulsion
W/C Pressure Reliefs
W/C Foot Rests
W/C Locks
Stairs
CURRENT LEVEL OF FUNCTION
Assistance
Assistive Devices / Comments
Bed Mob Roll / Turn
Bed Mob Sit / Supine
Scoot / Bridge
Transfers Sit / Stand
Transfers Bed / WheelChair
Toilet
Floor
Auto
Balance Static Sitting
Balance Dynamic Sitting
Balance Static Standing
Balance Dynamic Standing
W/C Propulsion
W/C Pressure Reliefs
W/C Foot Rests
W/C Locks
Stairs
Gait Assistance
Please Select
Independent
SBA
CGA
Min A
Mod A
Max A
Dependent
Gait Distance/Time
Gait Surfaces
Please Select
Level
Uneven
Stairs (Number/Condition)
Weight Bearing Status
Please Select
FWB
WBAT
PWB
TDWB
NWB
Adaptive Device(s)
Cane
Quad Cane
Crutches
Hemi Walker
Waler
Wheeled Walker
Gait Quality / Deviations / Posture
SUMMARY AND PHYSICAL THERAPY GOALS
Goals
Instruction Provided
Safety
Exercise
Other
Discharge Discussed With
Patient / Family
Case Manager
Physician
Other
Patient / Caregiver Aware and Agreeable to POC
Please Select
Yes
No
Rehab Potential
Equipment Needed
Orders
Physician orders obtained
Physician orders needed
Orders for PT evaluation only
Orders for PT services with specific treatments
Approximate Next Visit Date
PLAN FOR NEXT VISIT:
CARE COORDINATION
MD
PT/PTA
OT
ST
MSW
SN
HHA
Other
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