Amputee Physical Therapy Assessment Form
Patient Information
Name
Date of Assessment
Date of Birth
Medical Record Number
Amputation Details
Level of Amputation
Side
Left
Right
Bilateral
Date of Amputation
Cause of Amputation
Surgical/Healing Complications
Pain Assessment
Presence of Pain (Phantom/Surgical/Other)
Physical Assessment
Skin Condition
Edema
Sensation
Range of Motion
Muscle Strength
Residual Limb Length/Shape
Other Significant Findings
Functional Assessment
Mobility Status
Transfers
Use of Assistive Devices
Activities of Daily Living (ADLs)
Prosthetic Use (if applicable)
Goals & Plan
Short Term Goals
Long Term Goals
Plan/Recommendations
Therapist Information
Therapist Name
Signature
Date