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Physical Therapy Evaluation Template [Free Download]

A physical therapy evaluation is a crucial step in providing effective treatment and ensuring proper reimbursement. Whether you are a new graduate or a seasoned physical therapist, having a comprehensive evaluation template can greatly enhance your ability to provide quality care and meet documentation requirements.

In this article, we will explore the key components/requirements of a comprehensive physical therapy evaluation template and provide a customizable evaluation example to be utilized in practice.

Physical Therapy Evaluation Template

The Importance of a Comprehensive Physical Therapy Evaluation Template

The physical therapy evaluation serves as the foundation for a patient's plan of care and is essential for effective treatment. It allows the therapist to assess the patient's condition, develop a diagnosis, set goals, and create a plan of care tailored to the individual's needs. A well-documented evaluation is crucial for reimbursement purposes, as it provides the necessary information to support the medical necessity of therapy services.

Having a comprehensive evaluation template can help streamline the documentation process and ensure that all relevant information is captured. It serves as a guide, reminding the therapist of the key components that need to be addressed during the evaluation. By using a template, therapists can ensure that their documentation is consistent and defensible.

Creating a Comprehensive Physical Therapy Evaluation Template

Creating a comprehensive physical therapy evaluation template can help ensure that all necessary components are addressed and documented. Here is a step-by-step guide to developing your own template:

Preliminary Steps

Before starting the evaluation, review relevant information such as the patient's prescriptions, demographics, past medical history, and current medications. This information can be collected ahead of time and transferred directly to the patient's chart using digital patient intake forms.

Consider administering a patient-related outcome measure (PROM) at this stage to gather additional information about the patient's functional status and track progress over time.

Patient Information

The evaluation begins with gathering essential patient information, including their name, date of birth, contact information, and relevant demographic details. This section also includes space for insurance information, referral source, and any relevant consent forms.

Past Medical History

The past medical history section captures important information about the patient's overall health, previous medical conditions, surgeries, and hospitalizations. It is essential to understand the patient's medical background as it may influence their response to therapy and help identify any potential contraindications or precautions.

Medications and Allergies

Documenting the patient's current medications and any known allergies is crucial for ensuring safe and effective treatment. This information helps the therapist identify any potential drug interactions or side effects that may impact therapy sessions.

Subjective Examination

During the subjective examination, gather information about the patient's chief complaints, previous level of function, mechanism of injury, employment and work history, and medical and surgical history. Use open-ended questions to encourage the patient to provide detailed information and utilize structured templates or checklists to ensure comprehensive data collection.

Include the SINSS model (severity, irritability, nature, stage, and stability) to assess the severity and characteristics of the patient's condition. This model can help guide the therapist's clinical reasoning and treatment approach.

Physical Therapy Evaluation

Chief Complaint and History of Present Illness

In this section, the patient's primary reason for seeking physical therapy is documented. The therapist should encourage the patient to provide a detailed description of their symptoms, including the onset, duration, and any exacerbating or relieving factors. This information helps establish a baseline for treatment and guides the therapist in formulating appropriate goals and interventions.

Mechanism of Injury and Prior Level of Function

The mechanism of injury section records the patient's description of how their injury occurred, such as a fall, motor vehicle accident, or sports-related incident. This information helps the therapist understand the forces involved in the injury and determine any potential implications for treatment. The patient's prior level of function is also recorded in this section, which helps establish a baseline for measuring functional progress.

Surgical History

The patient's surgical history should be documented, including any prior surgeries or procedures related to their current condition. The therapist should inquire about the date of the surgery, type of procedure, and outcome or complications. This information can provide insight into the patient's medical background and help identify any potential contraindications or precautions during treatment sessions.

Subjective Example

Patient states he tore his R ACL playing basketball during men's league. He came down from getting a rebound and immediately felt a pop. He was able to walk off the court but something didn’t feel right. Reported some swelling that night and the next day with moderate pain and felt like his knee was going to give out on him, so he set up an appointment with Dr. Casperson who sent him for an MRI. MRI was (+) for an ACL tear. Opted to wait a few weeks for surgery due to a busy month at work and needing to plan for his recovery

Prior Functional Level: Patient was independent in all areas.


Type: Dull, Ache, Sharp

Current: 6/10 Best: 6/10 Worst 8/10

What makes the pain better? Patient states he takes Advil occasionally. Resting, elevating, and icing helps the most.

What makes the pain worse? Standing, sitting, or standing for long periods.

Objective Measures

Collect objective data through various measures such as range of motion assessments, muscle length testing, manual muscle testing, joint accessory motion testing, and special tests. These objective measures provide quantifiable data that can be used to track progress and guide treatment decisions.

  • Neighboring joints and systems screening

  • Active and passive range of motion collection

  • Muscle length testing;

  • Manual muscle testing;

  • Neurodynamic testing;

  • Palpation and joint accessory motion testing;

  • Additional outcome measures

  • Special tests

  • Gait analysis

Include additional outcome measures that are relevant to the patient's condition and goals. These measures can provide valuable information about the patient's functional status and help monitor changes over time.

Objective Example

Knee Flexion: Left A/PROM: 140/143 Right A/PROM: 110/116

Knee Extension: Left A/PROM: -3/-5 Right A/PROM: 5/0

LMMT: 4/5 RMMT: Not Tested (Post Op)

Special tests, including a Lachman test, McMurray test, and anterior drawer test were all positive for an ACL tear on the right side.

Gait: NWB on RLE using bilateral axillary crutches with TROM brace.

Posture: WB through L LE only while entering the clinic


Synthesize the information gathered during the subjective and objective examinations to develop a clear and concise assessment. Identify any impairments, functional limitations, and underlying causes of the patient's condition. Use evidence-based practice guidelines and clinical reasoning to develop a diagnosis that accurately reflects the patient's condition.

Provide a prognosis that includes the patient's potential for improvement and factors that may impact their outcomes. Consider the patient's motivation, comorbidities, acuity of the condition, and nature of the dysfunction or related disease processes.


With every assessment of the patient, there must also include a statement of the patient’s prognosis. Simply stating excellent, good, fair, or poor is no longer sufficient. Providing examples as to why you have assigned this prognosis is required. Some of these factors include:

  • Motivation;

  • Comorbidities and past medical history;

  • Acuity of the injury or primary complaint; or

  • Nature of the dysfunction or related disease processes.

Evaluation Complexity

Designate the complexity level of the evaluation using the appropriate CPT code. Consider factors such as the duration of the evaluation, history, examination, clinical presentation, and decision-making process when selecting the code.

Refer to the CMS guidelines and our guide to evaluation complexity for guidance on choosing the appropriate evaluation complexity code.

Assessment Example

The patient underwent surgery three days ago for a right anterior cruciate ligament reconstruction (R ACLr) using a bone-patellar tendon-bone (BPTB) autograft. The procedure was performed on March 3, 2023, by Dr. Casperson.

Following the surgery, the patient is experiencing a notable decrease in range of motion (ROM) in the affected limb, a reduction in the strength of the right lower extremity (RLE), poor balance, and a decrease in overall function as indicated by his Lower Extremity Functional Scale (LEFS) score. Additionally, the patient is displaying poor gait quality while ambulating into the clinic, and he is non-weight bearing (NWB) on the surgical leg. Moreover, the patient is reporting an increase in pain.

It is recommended that the patient undergo skilled physical therapy (PT) to aid in his recovery and facilitate his return to his prior level of function (PLOF). Problem Summary: Increased pain at right knee, decreased ROM of right knee, decreased strength of R LE, balance deficits in standing, difficulty with weight bearing activities, altered posture, impaired gait. Potential for Rehab: Excellent Complexity: Moderate


Set specific and measurable goals for the patient to achieve as a result of skilled physical therapy services. Utilize the SMART goal framework (specific, measurable, attainable, realistic, and time-bound) to ensure that the goals are meaningful and achievable.

These goals should align with the patient's functional needs and desired outcomes, serving as a roadmap for their treatment plan. Align the goals with the patient's personal therapy journey and involve them in the goal-setting process. This promotes patient engagement and increases their motivation to actively participate in their treatment.

Example Goals Short Term Goals

  1. By March 31, 2023, the patient should achieve full passive range of motion (PROM) in knee extension, reaching -5 degrees to match the range of motion in the left lower extremity (L LE).

  2. By March 31, 2023, the patient's goal is to enhance their knee flexion capability, aiming for an improvement to 115 degrees of flexion.

  3. By March 31, 2023, the patient is targeted to enhance their knee extension Isometric Quad Set (ISOM) strength, with the objective of achieving a 4/5 score on manual muscle testing (MMT).

  4. By March 31, 2023, the patient should be able to ambulate without experiencing pain or displaying an antalgic gait while utilizing Axillary crutches.

  5. By March 31, 2023 the patient will report a 50% reduction in knee pain at night, which will facilitate their ability to fall asleep more comfortably.

Long Term Goals

  1. By April 28, 2023, the patient is expected to achieve the ability to ambulate without displaying an antalgic gait, experiencing pain, or relying on assistive devices (AD).

  2. By May 26, 2023, the patient should be able to ascend and descend stairs without any knee pain. This improvement is crucial as it will enable the patient to perform work-related tasks, such as navigating the office facility, comfortably.

  3. By May 26, 2023, the patient's goal is to attain Quadriceps Index (QI) greater than 75%.

  4. By May 26, 2023, the patient aims to achieve Hamstrings Index (HI) greater than 75%.

  5. By May 26, 2023, the patient's objective is to improve their Lower Extremity Functional Scale (LEFS) score to over 40 out of 80.

Plan of Care

Develop a comprehensive plan of care that outlines the frequency and duration of therapy sessions, as well as the anticipated interventions and treatments. Consider the patient's goals, assessment findings, and evidence-based practice guidelines when determining the appropriate interventions.

Include the planned interventions, such as therapeutic exercises, manual therapy, neuromuscular re-education, and therapeutic modalities. Ensure that the interventions are specific and targeted to address the patient's impairments and functional limitations.

Plan of Care Example:

Duration: 12 Weeks

Frequency: 3x per week

Interventions: AROM/AAROM/PROM, balance and proprioception training, Therapeutic exercises, HEP, mobilization, posture training, Manual Therapy, Neuromuscular re-education.

Download Free Customizable Physical Therapy Evaluation Template

The comprehensive physical therapy evaluation template is a powerful tool for streamlining documentation and ensuring your documentation is consistently thorough and defensible. Get your FREE customizable Physical Therapy Evaluation Template. Don't miss out, download now!

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