Orthopedic Physical Therapy Exam Sheet
Name
Date
Age
Gender
Male
Female
Other
Referral/Diagnosis
Chief Complaint
History of Present Illness/Injury
Subjective
Mechanism of Injury
Symptoms
Pain Characteristics
Medications
Past Medical/Surgical History
Objective
Observation/Posture
Inspection (Swelling, redness, deformity)
Palpation
ROM (Active)
ROM (Passive)
Strength
Special Tests
Neurological (Sensation/Reflexes)
Functional Assessment
Gait/Assistive Devices
Assessment
Summary/Clinical Impression
Problem List
Goals
Plan
Treatment Plan
Frequency & Duration
Home Exercise Program
Recommendations
Therapist Name
Signature
Date