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Form from HIS OpenVista

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  5. 6/26/15
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June 26, 2015

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Creative Commons BY-NC 3.0 Legacy
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PHYSICAL THERAPY INITIAL EVALUATION

HIS

  1. StudyEvent: HIS
    1. HIS
General Info
SOCIAL/HEALTH HABITS(PAST & CURRENT)
Alcohol abuse
Smoker
Living Situation, Dwelling
Assisted Living, Residential Care
Home (Lives Alone)
Home with parent(s)
Home w/Significant Other
Home w/Spouse
Home w/Family (Children)
Home w/Friend (Caretaker)
Dependent in ADLs
Independent in ADLs
Nursing Home (NH)
Assisted Living Facility, Retirement Center
Requires Assistance with ADLs
Other
Stairs to enter
Stairs indoors
REMAIN ON FIRST FLOOR
Medical history
MEDICATIONS REVIEWED
Review of systems
cm
kg
beats/min
/min
mmHg
Edema
Ankle Edema
Foot Edema
Hand Edema
Knee Edema
Leg oedema, Edema of leg
INTEGUMENTARY within normal limits
MUSCULOSKELETAL WNL
NEUROMUSCULAR WNL
COMMUNICATION WNL
Orientation as to time, place and people
Memory loss, Loss of memory
EMOTIONAL/BEHAVIORAL RESPONSES WNL
LEARNING BARRIERS
Hearing impaired
Language/Needs interpreter
unable to read
Vision impaired
EDUCATION NEEDS
Education ADLs
Education Disease
Education Equipment
Education Exercise Program
Education Safety
Education Transfers
KEYS TO TEST AND MEASURES
Diagnosis
Cardiovascular Pattern(s)
Integumentary Pattern(s)
Musculoskeletal Pattern(s)
Neuromuscular Pattern(s)
PROGNOSIS, Goals, Interventions, Plan
Educated - family
Educated - patient
Educated - significant other
Educated - returns Demonstration
Educated - Verbalizes understanding