Eval Checklist

☐ 1. Reason for Referral / Main Concern

☐ Why are you here today?
☐ Biggest problem affecting daily life
☐ Onset / what changed?
☐ What worries you most?

☐ 2. Patient Goals (MOST IMPORTANT)

☐ What do you want to be able to do again?
☐ Top 1–3 goals
☐ “If therapy works, what will be different?”
☐ Most meaningful activity to return to:

→ _______________________________

☐ 3. Prior Level of Function (PLOF)

☐ ADLs (dress, bathe, toilet, feed)
☐ IADLs (cook, clean, meds, money, shopping)
☐ Mobility (walk, stairs, device?)
☐ Work / school
☐ Leisure / exercise

☐ 4. Current Function (CLOF)

☐ Same categories as above — what changed?
☐ Assistance level?
☐ Equipment used?
☐ Pain / fatigue limiting function?
☐ Time / safety issues?

☐ 5. Daily Routine (QUICK PICTURE)

☐ Walk me through a typical day
☐ Biggest struggle time of day
☐ Rest breaks / fatigue pattern
☐ Sleep quality

☐ 6. Home / Environment

☐ Lives with: ____________
☐ Stairs / barriers at home
☐ Bathroom setup (tub/shower/grab bars)
☐ Bedroom location
☐ Fall risks (rugs, lighting, clutter)

☐ 7. Support System

☐ Who helps you?
☐ How often?
☐ Reliable caregiver/transport?
☐ Emergency support?

☐ 8. Roles (WHAT MATTERS MOST)

☐ Worker / student
☐ Parent / caregiver
☐ Home roles
☐ Social roles
☐ Leisure identity

→ Most important role now: ____________

☐ 9. Key Occupational Areas (SCAN)

☐ ADLs independence changes
☐ IADLs (cooking, meds, finances, driving)
☐ Mobility / transfers
☐ Sleep
☐ Social participation
☐ Leisure loss

☐ 10. Medical / Safety Screen

☐ Dx / relevant PMH
☐ Falls or near-falls
☐ Precautions
☐ Hospitalizations / recent changes

☐ 11. Symptoms (HIGH YIELD)

☐ Pain
☐ Fatigue / endurance
☐ Weakness
☐ Balance issues
☐ Numbness/tingling
☐ Dizziness
☐ Vision changes
☐ Cognitive changes

☐ 12. Cognition / Safety

☐ Memory
☐ Attention
☐ Problem solving
☐ Insight into deficits
☐ Safety awareness
☐ Learning style

☐ 13. Psychosocial

☐ Mood (anxiety/depression/stress)
☐ Motivation
☐ Coping strategies
☐ Confidence/fear of movement
☐ Adjustment to condition

☐ 14. Equipment / DME

☐ Walker / cane / wheelchair
☐ Shower chair / grab bars
☐ Orthotics
☐ Other: ____________
☐ Using correctly? ☐ Y ☐ N

☐ 15. QUICK FUNCTIONAL MOBILITY SNAPSHOT

☐ Bed mobility
☐ Sit ↔ stand
☐ Transfers
☐ Walking / balance
☐ Stairs / community mobility

⭐ DON’T MISS (ASK THESE EVERY TIME)

☐ What is the hardest part of your day?
☐ What have you stopped doing because of this?
☐ What activity do you miss the most?
☐ What feels unsafe or you avoid?
☐ What do you want to get back FIRST?
☐ Anything I didn’t ask that matters?

☐ SENSATION

☐ Light touch
☐ Proprioception
☐ Numbness/tingling reported
Notes: ______________________

☐ TONE / MOTOR CONTROL

☐ Hypotonia
☐ Hypertonia/spasticity
☐ Clonus present?
☐ Synergy patterns
☐ Selective control present?

☐ COORDINATION

☐ UE coordination intact/impaired
☐ LE coordination intact/impaired
☐ Ataxia? tremor?

☐ STRENGTH (FUNCTIONAL OBSERVATION)

☐ Anti-gravity present?
☐ Weight-bearing tolerance
☐ Symmetry L vs R
Notes: ______________________

☐ BALANCE

☐ Static sitting
☐ Dynamic sitting
☐ Standing tolerance
☐ Reactive balance

☐ ENDURANCE

☐ <5 min tolerance
☐ 5–10 min
☐ 10–20 min
☐ >20 min
☐ Fatigue pattern during session

☐ COGNITION / SAFETY

☐ Alert/oriented
☐ Follows 1–2 step commands
☐ Safety awareness intact/impaired
☐ Insight into deficits

☐ FUNCTIONAL OBSERVATION SUMMARY

☐ Biggest limiting factor today: ____________
☐ Primary breakdown (strength, balance, endurance, cognition, pain): ____________

FUNCTIONAL STATUS (0–3 QUICK SCALE)

0 = I, 1 = Min A, 2 = Mod A, 3 = Max A/Dep

• ADLs: ____

• Transfers: ____

• Mobility: ____

• IADLs: ____

• Balance: ____

• Endurance: ____

LIMITING FACTORS (CHECK ALL THAT APPLY)

☐ Pain
☐ Fatigue
☐ Weakness
☐ Balance
☐ Coordination
☐ Cognition
☐ Fear/anxiety
☐ Environment
☐ Equipment issues

OBSERVED PERFORMANCE NOTES (FAST)

☐ Initiation
☐ Sequencing
☐ Safety awareness
☐ Speed
☐ Breaks needed
☐ Compensations

ASSISTIVE DEVICES

☐ None
☐ Cane
☐ Walker
☐ Wheelchair
☐ Orthosis
☐ Shower DME

Using appropriately? ☐ Yes ☐ No

QUICK FUNCTIONAL SNAPSHOT

☐ Bed mobility
☐ Sit ↔ stand
☐ Ambulation
☐ Stairs
☐ Toilet transfer
☐ Shower transfer