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Physio Initial Assessment Form

This physiotherapy initial assessment form collects information about a patient's name, age, contact details, occupation, referring doctor, chief complaint, duration and description of injury, pain details, functional impairments, diagnosis, and proposed treatment plan including frequency of visits, modalities, exercises, education, and follow up. The physiotherapist will use this information to develop an individualized treatment program for the patient.

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kitu_alagappan4720
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25K views

Physio Initial Assessment Form

This physiotherapy initial assessment form collects information about a patient's name, age, contact details, occupation, referring doctor, chief complaint, duration and description of injury, pain details, functional impairments, diagnosis, and proposed treatment plan including frequency of visits, modalities, exercises, education, and follow up. The physiotherapist will use this information to develop an individualized treatment program for the patient.

Uploaded by

kitu_alagappan4720
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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PHYSIOTHERAPY INITIAL ASSESSMENT FORM

DATE:

Patient Name: _____________________________________________________

Age/Sex:

Address:

Phone Number:

Occupation: __________________________________________

REFERRED: Yes No

Referring Doctor/Consultant: _________________________________________

Date of Referral: ____________________________________________________

CHIEF COMPLAINT/AILMENT/INJURY:

DURATION OF INJURY: __________________________

HAS YOUR CONDITION BEEN GETTING: WORSE SAME BETTER

Previous surgeries:

Medications:

PAIN:

Type/Description __________________________________________

Aggravates ________________________________________________

Eases ____________________________________________________

Are your symptoms: Constant Intermittent


NUMERIC RATING SCALE:

SITE OF PAIN:

FUNCTIONAL IMPAIRMENTS/DIFFICULTIES:

ACTIVITIES DIFFICULTIES
Diagnosis: _____________________________________________________

Treatment Plan:

Frequency of Visits (Required/Referred):

1. Electrotherapeutic Modalities:

2. Manual Concepts (If Any):

3. Therapeutic Exercises:

Patient Education:

Prognosis:

Follow Up:

Physio Signature: __________________


DATE NO OF SESSIONS AND PHYSIOTHERAPIST
REMARKS SIGNATURE
EXERCISE PRESCRIPTION CHART

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