Home Health Physical Therapy Evaluation Form
Patient Information
Patient Name
Date of Birth
Medical Record #
Evaluation Date
Referring Physician
Diagnosis
Subjective
Chief Complaint
History of Present Illness
Medications
Prior Level of Function
Home Environment
Objective
Vital Signs
Mental Status
Pain Assessment
ROM and Strength
Balance Assessment
Gait Assessment
Assistive Devices
Assessment
Clinical Assessment
Problem List
Plan
Frequency/Duration
Goals
Treatment Plan
Recommendations
Therapist Information
Therapist Name
License #
Signature
Date