Home Physical Therapy Assessment Form
Patient Information
Name
Date of Birth
Phone
Address
Emergency Contact
Referral Information
Referral Source
Diagnosis
Medical History
Relevant Medical History
Current Medications
Assessment
Mobility Status
Balance
Pain (location, severity)
Strength Assessment
Range of Motion
Home Environment
Home Safety Concerns
Assistive Devices/Equipment
Goals
Short Term Goals
Long Term Goals
Plan of Care
Plan
Frequency/Duration of Visits
Therapist Name/Signature
Date