Aquatic Physical Therapy Initial Evaluation Form
Patient Information
Full Name
Date of Birth
Date of Evaluation
Contact Number
Referring Physician
Diagnosis/Reason for Referral
Medical History
Relevant Medical Conditions
Current Medications
Allergies
Previous Surgeries/Injuries
Subjective Information
Chief Complaint
Pain Level (0-10)
Pain Description/Location
Mobility/Functional Limitations
Objective Assessment
Posture/Alignment
Range of Motion
Strength
Balance/Coordination
Gait
Aquatic Assessment
Comfort in Water
Ability to Enter/Exit Pool
Buoyancy & Support Needs
Swimming/Movement Skills
Precautions in Aquatic Environment
Assessment/Diagnosis
Clinical Impression
Goals
Short Term Goals
Long Term Goals
Plan of Care
Recommended Aquatic Interventions
Frequency/Duration
Progression Criteria
Therapist Information
Evaluator Name
Signature
Date