Pediatric Physical Therapy Evaluation

Patient Information

Name Date of Birth Age Gender Male Female Other Medical Diagnosis Referring Physician Date of Evaluation

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Reason for Referral

History

Birth and Developmental History Medical/Surgical History Family/Social History

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Subjective Information

Objective Findings

Observation/Posture ROM (Range Of Motion) Strength Tone/Reflexes Balance / Coordination Gait / Mobility Functional Skills Sensory / Perceptual Assistive Devices

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Assessment

Goals

Plan of Care

Treatment Frequency/Duration Interventions Recommendations

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Therapist Information

Name Credentials Signature Date