Spinal Cord Injury Physical Therapy Form
Patient Name
Date of Birth
Date of Assessment
Treating Therapist
Injury Level
Type of Injury
Complete
Incomplete
Date of Injury
Current Functional Status
Relevant Medical History
Presenting Problems/Goals
Physical Assessment (ROM, Strength, Tone, Sensation)
Mobility Assessment
ADL Assessment
Therapy Plan
Progress/Notes
Recommendations
Therapist Signature
Date