Home Health Physical Therapy Assessment
Patient Information
Patient Name
Date of Assessment
Date of Birth
MRN / ID
Referring Physician
Primary Diagnosis
Secondary Diagnosis
History & Subjective Report
History of Present Illness / Injury
Past Medical History
Medications
Allergies
Patient's Chief Complaint
Home Environment / Social History
Objective Examination
Vital Signs
Mental Status / Orientation
Pain Assessment
Range of Motion
Strength
Gait / Mobility
Transfers
Balance
Assistive Devices Used
Assessment
Summary/Impression
Rehabilitation Potential
Goals
Short-Term Goals
Long-Term Goals
Plan of Care
Treatment Plan
Frequency & Duration
Discharge Plan
Signature
Therapist Name
Date