Physical Therapy Patient Assessment Form
Patient Name
Date of Birth
Date
Referring Physician
Contact Information
Phone Number
Email
Address
Medical History
Primary Complaint / Reason for Visit
Onset Date
How did the injury/issue occur?
Previous Treatments or Surgeries
Current Medications
Relevant Medical Conditions
Assessment
Pain Level (0-10)
Pain Description (location, frequency, type of pain, etc.)
Functional Limitations
Goals for Physical Therapy
Therapist Notes
Observation & Assessment
Plan / Recommendations