Geriatric Physical Therapy Assessment
Patient Information
Name
Age
Date
Gender
Female
Male
Other
Medical Diagnosis
Subjective
Chief Complaint
History of Present Illness
Past Medical History
Medications
Social History
Objective
Observation/Posture
Functional Mobility
Balance Assessment
Range of Motion
Muscle Strength
Sensation
Other Tests
Assessment
Summary/Clinical Impression
Problem List
Prognosis
Plan
Treatment Goals
Intervention Plan
Frequency & Duration