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