Chugach Physical Therapy
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      • Therapists >
        • Rainy Diehl
        • Michelle Drake
        • Boyd Esplin
        • Sharon Frost
        • Karen Hansen
        • Jessica Hoffman
        • Dorothy Martin-Calkins
        • Linda Sheppard
      • Staff >
        • Clayton Gellerman
        • Tumelia Gilmore
        • Jeri Henry
        • Lezlie Robinson
        • Annamarie Williamson
    • South Anchorage Clinic >
      • Therapists >
        • Laura Croix
        • Joan Stassel
        • Stacey Szymanski
      • Staff >
        • Payton Hammon
        • Declan Macpherson-Clark
  • Evaluation Info/Forms
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Evaluation Info/Forms

What is an Evaluation?

An evaluation is a process wherein the physical therapist makes clinical judgments based on data gathered during an examination. The examination includes taking a comprehensive history, performing a review of systems, and conducting tests and measures. Tests and measures may include but are not limited to tests of range of motion, function/motor, muscle performance, joint integrity, neuromuscular status, and review of orthotic/prosthetic devices. The physical therapist will evaluate the examination findings, establish a physical therapy diagnosis, determine the prognosis, and develop a plan of care that includes the anticipated goals and expected outcomes, interventions to be used, and anticipated discharge plans.

If a patient has been discharged from care for any reason or has not been treated within 30 days of the last treatment, a new evaluation will be performed should the patient return to the clinic.

A re-evaluation is a process wherein the physical therapist re-examines the patient to evaluate progress and to modify or redirect intervention and/or revise goals and expected outcomes. Re-examination may be indicated more than once during a plan of care. Tests and measures include but are not limited to those performed in an evaluation. The physical therapist will modify/update the plan of care as is indicated and suppot medical necessity of skilled intervention.

What Do I Bring?

For your initial evaluation, you should bring the following:
  • Filled out paperwork (or come in early at fill it out at the clinic!) found in the "Evaluations Forms" sections below
  • Photo ID
  • Insurance Card(s)
  • Physician Referral

Wear comfortable clothes that allow access to the body part being treated and tennis shoes.


Evaluation Forms

Please print and complete the "Demographics," "Cancellation/No Show Policy," "Treatment Authorization," "Health Info," and one standardized test and bring them to your evaluation.

Demographics

Demographics.pdf
File Size: 120 kb
File Type: pdf
Download File

Cancellation/No Show Policy

Cancellation/No Show Policy.pdf
File Size: 98 kb
File Type: pdf
Download File

Treatment Authorization

Treatment Authorization.pdf
File Size: 87 kb
File Type: pdf
Download File

Health Info

Health Info.pdf
File Size: 119 kb
File Type: pdf
Download File


​Standardized Tests

The following forms are specific for your diagnosis or reason for coming to physical therapy. You only need to complete the form that applies to your diagnosis. For example, if you are coming in for a knee replacement, you only need to fill out the KOOS, JR form. These diagnostic specific forms are in addition to the four forms above. If you have any questions about which forms you need to fill out, please don't hesitate to call us at (907) 743-3333. You are always more than welcome to come to your appointment 20-30 minutes before your evaluation and fill the paperwork out in our office.
Dizzy/Balance
Dizziness Handicap Inventory (DHI)
Dizziness Handicap Inventory.pdf
File Size: 167 kb
File Type: pdf
Download File


Neck
Neck Disability Index (NDI)
Neck Disability Index.pdf
File Size: 105 kb
File Type: pdf
Download File


Shoulder, Arm, Wrist, Hand
 Upper Extremity Functional Scale (UEFS)
Upper Extremity Functional Scale.pdf
File Size: 149 kb
File Type: pdf
Download File


Back Pain
Oswestry Disability Index (ODI) aka Oswestry Low-Back Assessment
Oswestry Low Back Assessment.pdf
File Size: 105 kb
File Type: pdf
Download File


Hip, Thigh, Knee, Ankle, Foot
Lower Extremity Functional Scale (LEFS)
Lower Extremity Functional Scale.pdf
File Size: 150 kb
File Type: pdf
Download File


Hip/Hip Joint Replacement
HOOS, JR
​(Hip Osteoarthritis Outcome Score, Joint Replacement)
HOOS, JR.pdf
File Size: 189 kb
File Type: pdf
Download File


Knee/Knee Joint Replacement
KOOS, JR
(Knee Osteoarthritis Outcome Score, Joint Replacement)
KOOS, JR
File Size: 218 kb
File Type: pdf
Download File

Contact US


Telephone

Midtown: (907) 743-3333
​South: (907) 646-6006

Fax

Midtown: (907) 272-8164
​South: (907) 644-9090
  • Home
  • About Us
    • Services
    • Contact Us
  • Our Team
    • Midtown Clinic >
      • Therapists >
        • Rainy Diehl
        • Michelle Drake
        • Boyd Esplin
        • Sharon Frost
        • Karen Hansen
        • Jessica Hoffman
        • Dorothy Martin-Calkins
        • Linda Sheppard
      • Staff >
        • Clayton Gellerman
        • Tumelia Gilmore
        • Jeri Henry
        • Lezlie Robinson
        • Annamarie Williamson
    • South Anchorage Clinic >
      • Therapists >
        • Laura Croix
        • Joan Stassel
        • Stacey Szymanski
      • Staff >
        • Payton Hammon
        • Declan Macpherson-Clark
  • Evaluation Info/Forms
  • FAQ
    • Preferred Providers
    • Insurance & Billing
    • Products
  • Fitness Center
  • Blog