Physical Therapy Evaluation
Subjective
Pain Scale
0/10
1/10
2/10
3/10
4/10
5/10
6/10
7/10
8/10
9/10
10/10
Location
Onset
Mechanism of Injury
Aggravating Factors
Easing Factors
Imaging
Hobbies
Occupation
Objective
Shoulder
Elbow
Wrist
Hip
Knee
Ankle
Cervicothoracic
Lumbosacral
Shoulder
Strength (Left)
Flexion:
5
4
3
2
1
0
+
-
/5
Extension:
5
4
3
2
1
0
+
-
/5
Abduction:
5
4
3
2
1
0
+
-
/5
External Rotation:
5
4
3
2
1
0
+
-
/5
Internal Rotation:
5
4
3
2
1
0
+
-
/5
Active Range of Motion (Left)
Flexion
deg
Extension
deg
Abduction
deg
External Rotation
deg
Internal Rotation
deg
Passive Range of Motion (Left)
Flexion
deg
Extension
deg
Abduction
deg
External Rotation
deg
Internal Rotation
deg
Strength (Right)
Flexion:
5
4
3
2
1
0
+
-
/5
Extension:
5
4
3
2
1
0
+
-
/5
Abduction:
5
4
3
2
1
0
+
-
/5
External Rotation:
5
4
3
2
1
0
+
-
/5
Internal Rotation:
5
4
3
2
1
0
+
-
/5
Active Range of Motion (Right)
Flexion
deg
Extension
deg
Abduction
deg
External Rotation
deg
Internal Rotation
deg
Passive Range of Motion (Right)
Flexion
deg
Extension
deg
Abduction
deg
External Rotation
deg
Internal Rotation
deg
Observation
Palpation
Joint Mobility
Special Tests
Elbow
Strength
Flexion:
5
4
3
2
1
0
+
-
/5
Extension:
5
4
3
2
1
0
+
-
/5
Active Range of Motion
Flexion
deg
Extension
deg
Passive Range of Motion
Flexion
deg
Extension
deg
Strength
Flexion:
5
4
3
2
1
0
+
-
/5
Extension:
5
4
3
2
1
0
+
-
/5
Active Range of Motion
Flexion
deg
Extension
deg
Passive Range of Motion
Flexion
deg
Extension
deg
Observation
Palpation
Joint Mobility
Special Tests
Wrist
Strength
Flexion:
5
4
3
2
1
0
+
-
/5
Extension:
5
4
3
2
1
0
+
-
/5
Radial Deviation:
5
4
3
2
1
0
+
-
/5
Ulnar Deviation:
5
4
3
2
1
0
+
-
/5
Pronation:
5
4
3
2
1
0
+
-
/5
Supination:
5
4
3
2
1
0
+
-
/5
Grip:
5
4
3
2
1
0
+
-
/5
Active Range of Motion
Flexion
deg
Extension
deg
Radial Deviation
deg
Ulnar Deviation
deg
Pronation
deg
Supination
deg
Passive Range of Motion
Flexion
deg
Extension
deg
Radial Deviation
deg
Ulnar Deviation
deg
Pronation
deg
Supination
deg
Strength
Flexion:
5
4
3
2
1
0
+
-
/5
Extension:
5
4
3
2
1
0
+
-
/5
Radial Deviation:
5
4
3
2
1
0
+
-
/5
Ulnar Deviation:
5
4
3
2
1
0
+
-
/5
Pronation:
5
4
3
2
1
0
+
-
/5
Supination:
5
4
3
2
1
0
+
-
/5
Grip:
5
4
3
2
1
0
+
-
/5
Active Range of Motion
Flexion
deg
Extension
deg
Radial Deviation
deg
Ulnar Deviation
deg
Pronation
deg
Supination
deg
Passive Range of Motion
Flexion
deg
Extension
deg
Radial Deviation
deg
Ulnar Deviation
deg
Pronation
deg
Supination
deg
Observation
Palpation
Joint Mobility
Special Tests
Hip
Strength (Left)
Flexion:
5
4
3
2
1
0
+
-
/5
Extension:
5
4
3
2
1
0
+
-
/5
ABDuction:
5
4
3
2
1
0
+
-
/5
ADDduction:
5
4
3
2
1
0
+
-
/5
External Rotation:
5
4
3
2
1
0
+
-
/5
Internal Rotation:
5
4
3
2
1
0
+
-
/5
Active Range of Motion (Left)
Flexion
deg
Extension
deg
Abduction
deg
External Rotation
deg
Internal Rotation
deg
Passive Range of Motion (Left)
Flexion
deg
Extension
deg
Abduction
deg
External Rotation
deg
Internal Rotation
deg
Strength (Right)
Flexion:
5
4
3
2
1
0
+
-
/5
Extension:
5
4
3
2
1
0
+
-
/5
ABDuction:
5
4
3
2
1
0
+
-
/5
ADDuction:
5
4
3
2
1
0
+
-
/5
External Rotation:
5
4
3
2
1
0
+
-
/5
Internal Rotation:
5
4
3
2
1
0
+
-
/5
Active Range of Motion (Right)
Flexion
deg
Extension
deg
Abduction
deg
External Rotation
deg
Internal Rotation
deg
Passive Range of Motion (Right)
Flexion
deg
Extension
deg
Abduction
deg
External Rotation
deg
Internal Rotation
deg
Observation
Palpation
Joint Mobility
Special Tests
Knee
Strength
Flexion:
5
4
3
2
1
0
+
-
/5
Extension:
5
4
3
2
1
0
+
-
/5
Active Range of Motion
Flexion
deg
Extension
deg
Passive Range of Motion
Flexion
deg
Extension
deg
Strength
Flexion:
5
4
3
2
1
0
+
-
/5
Extension:
5
4
3
2
1
0
+
-
/5
Active Range of Motion
Flexion
deg
Extension
deg
Passive Range of Motion
Flexion
deg
Extension
deg
Observation
Palpation
Joint Mobility
Special Tests
Ankle
Strength
Dorsiflexion:
5
4
3
2
1
0
+
-
/5
Plantarflexion:
5
4
3
2
1
0
+
-
/5
Inversion:
5
4
3
2
1
0
+
-
/5
Eversion:
5
4
3
2
1
0
+
-
/5
Active Range of Motion
Dorsiflexion
deg
Plantarflexion
deg
Inversion
deg
Eversion
deg
Passive Range of Motion
Dorsiflexion
deg
Plantarflexion
deg
Inversion
deg
Eversion
deg
Strength
Dorsiflexion:
5
4
3
2
1
0
+
-
/5
Plantarflexion:
5
4
3
2
1
0
+
-
/5
Inversion:
5
4
3
2
1
0
+
-
/5
Eversion:
5
4
3
2
1
0
+
-
/5
Active Range of Motion
Dorsiflexion
deg
Plantarflexion
deg
Inversion
deg
Eversion
deg
Passive Range of Motion
Dorsiflexion
deg
Plantarflexion
deg
Inversion
deg
Eversion
deg
Observation
Palpation
Joint Mobility
Special Tests
Cervical & Thoracic
Strength
Flexion:
5
4
3
2
1
0
+
-
/5
Extension:
5
4
3
2
1
0
+
-
/5
Right Rotation:
5
4
3
2
1
0
+
-
/5
Left Rotation:
5
4
3
2
1
0
+
-
/5
Right Sidebending:
5
4
3
2
1
0
+
-
/5
Left Sidebending:
5
4
3
2
1
0
+
-
/5
Active Range of Motion
Flexion
deg
Extension
deg
Right Rotation
deg
Left Rotation
deg
Right Sidebending
deg
Left Sidebending
deg
Passive Range of Motion
Flexion
deg
Extension
deg
Right Rotation
deg
Left Rotation
deg
Right Sidebending
deg
Left Sidebending
deg
Observation
Palpation
Joint Mobility
Special Tests
Lumbar & Sacrum
Strength
Flexion:
5
4
3
2
1
0
+
-
/5
Extension:
5
4
3
2
1
0
+
-
/5
Right Rotation:
5
4
3
2
1
0
+
-
/5
Left Rotation:
5
4
3
2
1
0
+
-
/5
Right Sidebending:
5
4
3
2
1
0
+
-
/5
Left Sidebending:
5
4
3
2
1
0
+
-
/5
Active Range of Motion
Flexion
deg
Extension
deg
Right Rotation
deg
Left Rotation
deg
Right Sidebending
deg
Left Sidebending
deg
Passive Range of Motion
Flexion
deg
Extension
deg
Right Rotation
deg
Left Rotation
deg
Right Sidebending
deg
Left Sidebending
deg
Observation
Palpation
Joint Mobility
Special Tests
Assessment
Structural Impairments:
Activity Limitations:
Plan
Frequency
1x/week
2x/week
3x/week
Duration
4-6 weeks
6-8 weeks
8-10 weeks
10-12 weeks
Submit