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Physical Therapist Evaluation Form Template

Streamline Patient Feedback with Our Evaluation Template

Collecting honest feedback is crucial for improving your physical therapy services. This evaluation form template empowers you to gather valuable insights from your patients, helping you refine treatment plans and enhance care quality. It offers customizable structures to easily assess therapy effectiveness, monitor patient progress, and secure ongoing communication, all while being accessible across any device. Try out the live template to see how it can efficiently fulfill your clinic's needs.

Use this Template (FREE) Live Preview
Full name
Date of birth
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Email address
Mobile phone number
Emergency contact name
Emergency contact phone
Preferred contact method
Phone
Email
Text message
No preference
How were you referred to us?
Physician
Self
Friend/Family
Coach/Trainer
Other
Please Specify:
Primary area of concern
Briefly describe your primary concern
When did your symptoms begin? (approximate if unsure)
How did this begin?
Sudden injury
Gradual onset
Post-surgical
Chronic (3+ months)
Not sure/Other
What was the cause or mechanism?
Sports
Work-related
Motor vehicle accident
Fall
Overuse/repetitive
Unknown/Other
Pain level now
Pain level at worst in the past week
Symptoms you are experiencing (select all that apply)
Please Specify:
Activities that make symptoms worse (select all that apply)
Please Specify:
In the past month, have you had any of the following: unexplained weight loss, fever or night sweats, loss of bowel/bladder control, or rapidly worsening weakness?
Yes
No
Current medications (name and dose if known)
Allergies (medications, latex, adhesives, etc.)
Please indicate any of the following conditions you have been diagnosed with
Please Specify:
Prior surgeries relevant to this problem (with year if known)
Have you had physical therapy for this problem before?
Yes
No
Occupation
Physical demands at work
Mostly sitting
Light physical
Moderate physical
Heavy physical
Varies
Current activities you find difficult (select all that apply)
Please Specify:
What are your goals for physical therapy?
Preferred appointment days
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Preferred time of day
Morning
Midday
Afternoon
Evening
No preference
I consent to evaluation and treatment by a licensed physical therapist
Yes
No
Signature (type your full name to sign)
Signature date
I acknowledge receipt or availability of the Notice of Privacy Practices (HIPAA)
Yes
No
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Paper art illustration depicting a physical therapist evaluation form with checkboxes and blank fields for patient data

When to use this form

Use this form when you need a structured baseline for a new patient after surgery, sprain, or a flare-up. It also fits progress checks (for example at 4 to 6 weeks), return-to-sport decisions, and workers comp cases where you must document objective findings and goals. Pair it with a Patient intake form to pre-collect demographics and the chief complaint, and a New patient information form to speed insurance and contacts. In multi-clinic teams, it standardizes range of motion, strength, gait, and pain scores so any therapist can pick up care. The result: clear goals, a focused plan of care, and defensible notes for payers and referring providers.

Must Ask Physical Therapist Evaluation Questions

  1. What is your primary concern and when did it begin?

    This frames the problem and phase of healing, which guides load, frequency, and precautions. Onset and mechanism help you screen for acute issues that may need imaging or referral.

  2. Where do you feel symptoms, how severe are they (0-10), and what makes them better or worse?

    Location, intensity, and triggers point to involved tissues and patterns. It improves your hypothesis and helps set starting activities the patient can tolerate.

  3. Which activities, work tasks, or sports are you struggling with right now?

    Functional limits tie goals to real-life tasks and support measurable outcomes. You can prioritize tests and select interventions that match their daily demands.

  4. What prior injuries, surgeries, or conditions do you have, and are there any red flags such as numbness, fever, or unexplained weight loss?

    History and red flags reduce risk and shape your plan and precautions. If you need deeper detail, collect it with a Medical history form.

  5. What medications, allergies, or implanted devices should we know about?

    These factors affect pain levels, healing, and modality choices. Capture sensitive details securely with a HIPAA Medical history form.

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