Physical Therapy Initial Assessment Form
Patient Information
Full Name
Date of Birth
Sex
Male
Female
Other
Address
Phone Number
Email
Referring Physician
Physician Name
Medical Diagnosis
Subjective History
Chief Complaint / Reason for Visit
Onset & Duration
Symptoms Description
Previous Treatment
Medical History
Relevant Medical/Surgical History
Current Medications
Allergies
Objective Assessment
Vital Signs
Musculoskeletal Exam
Range of Motion
Strength
Neurological Exam
Assessment
Problem List / Clinical Impression
Plan
Treatment Plan & Goals
Frequency & Duration of Therapy
Therapist Name
Date
Signature