Manual Therapy Evaluation Checklist
Date:
Patient Name:
Therapist Name:
Subjective Information
Reason for Visit / Chief Complaint:
Pain Description (location, intensity, duration, type):
Objective Assessment
Test/Observation
Findings
Posture
Range of Motion
Muscle Strength
Palpation
Joint Mobility
Special Tests
Manual Therapy Techniques
Technique
Area Treated
Response/Effect
Pain Assessment
None
Mild
Moderate
Severe
Pain Scale (0-10):
Assessment & Plan
Summary/Assessment:
Treatment Plan/Recommendations: