Title Page
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Patient Name
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Assigned Physical Therapist
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Conducted on
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Location
Subjective Data
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Age
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Race
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Gender
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Chief complaint
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History of Present Illness (location, quality, severity, timing, setting, alleviating/ aggravating factors, associated signs and symptoms)
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Past Medical History (allergies, current medication, injuries, hospitalizations, surgeries)
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Family History
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Social History
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Review of Systems
Objective Data
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Height (in)
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Weight (lbs)
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BMI
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Temperature
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Blood Pressure (BP)
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General Appearance
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Laboratory Results
Assessment
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General Observations
Plan
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Treatment Plan
Completion
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Additional Notes
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General Observations
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Name & Signature of Attending Medical Practitioner
