Transcription of PT/OT INITIAL EVALUATION REPORT - OrthoNet-Online.com
1 Strength ( 0-5 ) Motio n Grade Range of Motion Motio n PROM AROM Today s Date: PT/OT INITIA L EVALUATION REPORT Insurance Company: Pa tient Name: Pa tient ID #: Date of Birth / Age: Date Of Injury: / / Date Of Surgery: / / ICD-10 Code(s): Diagnosis: Referri ng Physician: Referri ng Physician ID #: Therapy Office: Discipline: PT / OT OBJECTIVE FINDINGS Invol ved Region: Left / Right / N/A How / Where In jury Occurred: Work Related? Yes No Pertinent Hist ory: Pain: Pain Scale: /10 Nature: constant / intermittent / localized / radiati ng Functional Deficits / Additional Information: Specific Treatment Plan: Treatment Goals: Projected Frequency / Duration of Treatment Therapist Signature: Printed Therapist Name and License #: Copyright 2015 OrthoNet, LLC Created: 9/99 / Revised: 1/12, 10/15
