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University of Utah Department
of Physical Therapy
Students Pro Bono ClinicLUMBAR EVALUATION FORM
Date:
Pt name:
Diagnosis:
Referred by:
Visit #:
Time In:Pt number:Time Out:Patient Information:
Patient
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01
To fill out a physical therapy form, follow these steps:
02
Start by writing your personal information at the top of the form, including your name, address, contact number, and date of birth.
03
Fill in any medical history or previous injuries that may be relevant to your physical therapy treatment.
04
Provide details about your current condition or injury for which you are seeking physical therapy. Be as specific as possible.
05
Indicate any medications you are currently taking or allergies you may have.
06
Complete any additional sections or questions on the form, such as insurance information or emergency contact details.
07
Review the completed form for any errors or missing information before submitting it to your physical therapist.
Who needs of physical formrapy?
01
Physical therapy is beneficial for various individuals, including:
02
- Individuals recovering from surgery or injury
03
- Athletes looking to enhance their performance or prevent injuries
04
- Individuals with chronic pain or mobility issues
05
- People with neurological conditions such as stroke or multiple sclerosis
06
- Individuals with musculoskeletal disorders or conditions like arthritis
07
- Children with developmental delays or physical disabilities
08
- Pregnant women experiencing back pain or other musculoskeletal discomfort
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- Individuals looking to improve their overall fitness and flexibility.
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What is of physical formrapy?
Physical therapy is a healthcare profession focused on improving and restoring a person's physical function and mobility.
Who is required to file of physical formrapy?
Patients who have received physical therapy services are required to file a physical therapy form.
How to fill out of physical formrapy?
Patients can fill out a physical therapy form by providing information about their medical history, current symptoms, and goals for therapy.
What is the purpose of of physical formrapy?
The purpose of physical therapy is to help individuals recover from injuries, surgeries, or manage chronic conditions through exercise, manual therapy, and education.
What information must be reported on of physical formrapy?
The physical therapy form must include the patient's personal information, medical history, current symptoms, treatment plan, and progress notes.
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