Home Health Physical Therapy Evaluation

[YOUR COMPANY NAME]

Date: [DATE]

Introduction: This evaluation form has been carefully designed to assess your health status and functional abilities in the comfort of your home. It serves as a crucial tool in creating a personalized treatment plan to address your specific needs and improve your overall well-being. Please take your time to fill in the following information accurately, as it will assist our licensed physical therapists in conducting a comprehensive evaluation.

Home Health Physical Therapy Evaluation Form
Patient Information
Full Name:
Date of Birth:
Health Status
Current Medications:
Known Allergies:
Past Surgeries:
Functional Evaluation
Mobility:
Balance and Coordination:
Fine Motor Skills:
Functional Limitations
Difficulty in Moving:
Difficulty in Performing Daily Activities:
Any Other Functional Limitations:
Objective Measures
Blood Pressure (BP):
Heart Rate (HR):
Respiratory Rate (RR):

Confidentiality Notice: The information provided will be treated with utmost confidentiality and will only be utilized to create an individualized treatment plan for the patient.