Pediatric Physical Therapy Evaluation Form
Patient Information
Child's Name
Date of Birth
Assessment Date
Parent/Guardian Name
Phone
Email
Referring Physician
Diagnosis/Reason for Referral
Medical History
Relevant Medical Conditions / Surgeries
Current Medications
Allergies
Developmental Milestones
Describe age achieved for milestones (e.g., sitting, crawling, walking)
Family Concerns & Goals
Concerns
Goals for Therapy
Clinical Observations
Posture & Alignment
Movement Patterns
Tone & Reflexes
Balance/Coordination
Strength
Range of Motion
Other Observations
Standardized Testing
Test(s) Used and Results
Summary & Recommendations
Clinical Impressions
Recommended Interventions
Frequency / Duration of Therapy
Evaluator's Name
Credential(s)
Date