Physical Therapy Comprehensive Initial Evaluation Mobile App

Included Fields

Customize to add, remove, or edit any of the fields below.

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  Client Name:

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  Date of Birth:

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  Physician:

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  Employer:

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  Date of Eval:

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  Date of Onset:

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  Diagnosis:

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  Relevant History:

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  Employment Data:

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  Currently Working:

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  Restricted Duty:

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  Physical Demand Level:

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  Treatment Report:

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  Objective Summary:

• 

  Pain Tools Used:

• 

  Dallas

• 

  Oswestry

• 

  Ransford

• 

  VAS

• 

  Waddell

• 

  Other(s)

• 

  Other(s):

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  Prognosis:

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  Rehabilitation Potential:

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  Plan:

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  Treatment:

• 

  Frequency:

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  Duration:

• ...and More!