Sports Injury Physical Therapy Evaluation
Patient Name
Date
DOB
Sport
Referring Physician
Injury Date
Subjective
Chief Complaint
History of Present Injury
Pain Scale (0-10)
Location of Pain
Type of Pain
Previous Treatments
Objective
Observation/Posture
Range of Motion (ROM)
Strength
Special Tests
Palpation
Functional Assessment
Assessment
Clinical Impression
Rehabilitation Potential
Plan
Treatment Plan
Goals
Frequency/Duration
Therapist Name
Signature
Date