骨科物理治疗部门评估表

_________________________________ 注释( 阳性) :___________________________________________________________________ 8. 功能性活动:□独立□需辅具进行 ADL 及 IADL: □腋拐□其他: ___________________ 9. 其他: _______________________________________________________________________ 编号: 4.11.1.1 【C】3.1 主要问题: 治疗计划: 物理治疗目标: 1. 短期目标: ___________________________________________________________________ ______________________________________________________________________________ 2. 中期目标: ___________________________________________________________________ ______________________________________________________________________________ 3. 长期目标: ___________________________________________________________________ ______________________________________________________________________________ 物理治疗师签名: _____________ 日期: ________________