Aquatic Physical Therapy Assessment Form
Patient Information
Name
Date of Birth
Phone
Email
Address
Medical History
Primary Diagnosis
Current Medications
Allergies
Precautions/Contraindications
Aquatic Safety Screening
Open Wounds
Incontinence
History of Seizures
Heart conditions
Other conditions
Additional Safety Concerns
Functional Assessment
Mobility Level
Independent
Requires Assistive Device
Requires Assistance
Pain Level (0-10)
Patient Goals
Therapist Notes
Assessment Findings
Plan/Recommendations
Therapist Name
Date