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PT/OT INITIAL EVALUATION REPORT Insurance Company Today s Date Patient Name Patient ID Date of Birth / Age Date Of Injury ICD-10 Code s / Date Of Surgery Diagnosis Referring Physician Therapy Office Discipline OBJECTIVE FINDINGS Strength 0-5 Motion PT OT Involved Region Left / Right / N/A Grade How / Where Injury Occurred Range of Motion PROM Work Related AROM Yes No Pertinent History Pain Pain Scale /10 Nature constant / intermittent / localized / radiating Functional Deficits / Additional...

How to fill out initial evaluation form

How to fill out initial evaluation form:

1. Start by providing your personal information such as your name, contact details, and any relevant identification numbers.
2. Proceed to answer the questions accurately and honestly. These questions will typically cover various aspects such as your medical history, current health conditions, lifestyle habits, and any goals or ailments you wish to address.
3. Take your time to read each question carefully and provide as much detail as possible. Some questions may require additional information or explanations, so make sure to provide them accordingly.
4. If you are unsure about any question or require clarification, do not hesitate to seek assistance from a healthcare professional or the form administrator.
5. Review your answers before submitting the form to ensure accuracy and completeness. This will help healthcare providers get a comprehensive understanding of your situation and provide appropriate recommendations or treatment plans.

Who needs initial evaluation form:

1. Individuals seeking medical or healthcare services may be required to fill out an initial evaluation form. Such forms are commonly used by doctors, therapists, and other healthcare professionals.
2. Employers may also require their employees to fill out initial evaluation forms for certain purposes, such as assessing job performance, identifying training needs, or implementing workplace safety measures.
3. Insurance companies may ask policyholders to complete initial evaluation forms to gather necessary information to determine coverage eligibility or assess claim requests.

In summary, anyone who needs to provide relevant information about themselves or their situation in a standardized format may be required to fill out an initial evaluation form.

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What is initial evaluation form?

The initial evaluation form is a document that gathers relevant information about a particular subject or situation at the beginning of an evaluation process.

Who is required to file initial evaluation form?

The individuals or organizations responsible for conducting the evaluation are typically required to file the initial evaluation form.

How to fill out initial evaluation form?

The initial evaluation form can be filled out by providing the requested information in the designated fields or sections of the form.

What is the purpose of initial evaluation form?

The purpose of the initial evaluation form is to collect necessary information and set a baseline for further evaluation or assessment.

What information must be reported on initial evaluation form?

The specific information to be reported on the initial evaluation form may vary depending on the nature of the evaluation, but generally, it includes details about the subject, objectives, methods, timeline, and stakeholders.