Worker's Compensation Physical Therapy Initial Evaluation

Patient Information

Patient Name

Date of Birth

Date of Evaluation

Claim Number

Employer Insurance Carrier Referring Physician

Subjective

History of Present Illness/Injury Mechanism of Injury Date of Injury Previous Treatment Current Symptoms Pain Level (0-10) Aggravating/Relieving Factors Functional Limitations

Objective

Observation/Posture Range of Motion Strength Palpation Special Tests Neurological Other Relevant Findings

Assessment

Summary/Clinical Impression Problem List

Plan

Goals Treatment Plan Frequency/Duration Home Exercise Program

Therapist Name

Signature

Date