Chronic Pain Physical Therapy Evaluation
Patient Information
Name
Date of Evaluation
Date of Birth
Medical Record Number
Subjective
Chief Complaint
History of Present Illness
Pain Description (Location, Quality, Severity, Duration, Frequency, Aggravating & Alleviating Factors)
Pain Scale (0-10)
Prior Treatments/Interventions
Medications
Patient Goals
Social History (work status, family support, activity level, etc.)
Objective
Posture
Gait Analysis
Range of Motion (ROM)
Strength
Palpation
Neurological Examination (sensation, reflexes, coordination)
Special Tests
Functional Assessment (e.g. sit to stand, balance, ADLs)
Assessment
Physical Therapy Diagnosis
Contributing Factors
Prognosis
Plan
Treatment Interventions
Frequency and Duration
Home Exercise Program
Therapist Name
Signature
Date