Free physiotherapy template

Physiotherapy assessment format and form, with sample entries

A free physiotherapy assessment format that runs from history to treatment plan, with a sample entry under each section.

History to treatment plan, in order
Red-flag screen records every answer
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What's inside

Subjective
Safety Screening
Objective Examination
Assessment
Goals
Treatment Plan
Therapist Sign-off

Physiotherapy Initial Assessment

Patient		Patient ID
Date of birth		Assessment date
Therapy		Therapist
Languages		Referred by

Subjective

Presenting complaint

History of present condition

Past medical and surgical history

Medications and investigationsRecord what is reported or documented; do not interpret investigations here.

Pain

Location	Description	Pain Scale Used and Rating	Aggravating Factors	Easing Factors	24-hour Pattern

Social history and occupation

Patient goals and expectations

Safety Screening

Red flag screening findings

Objective Examination

Observation and posture

Range of Motion

Joint / Movement	Left	Right	Method / Notes

Strength

Muscle Group / Movement	Left	Right	Method / Notes

Neurological findings

Special tests and palpationName each test performed and record the observed result.

Function

Activity	Current Level	Assistance / Aids	Notes
Bed mobility
Transfers
Gait
Stairs
Balance

Assessment

Clinical reasoning summary

Problem List	Related Findings

Goals

Goal	Timeframe	How It Will Be Measured

Treatment Plan

Planned interventions

Home exercise and advice

Frequency and review

Therapist Sign-off

Therapist	Designation	Registration	Date

How to fill it in

Subjective
The complaint in the patient's words, its onset and course, and treatment tried so far.
More guidance
Open with the complaint in the patient's own words, then onset, mechanism, duration and how the problem has behaved since. Record treatment already tried for this episode and what it changed. For medications and investigations, list what the patient reports or brings, with dates, and leave interpretation for the Assessment section. If a son, daughter-in-law or attendant gave most of the history, say so: it changes how a later reader weighs the account.
Pain
One row per painful area, with the named scale, best and worst ratings, and triggers.
More guidance
Use one row per painful area, and add a body chart if your clinic keeps one. Write the name of the pain scale beside every rating, and record the rating at best and at worst over a stated period so later notes have a fixed comparison point. Aggravating and easing factors are most useful when they are specific and timed. The 24-hour pattern, such as morning stiffness and how long it lasts or night waking, also feeds the safety screen that follows.
Social history, occupation and patient goals
Work, travel, home set-up and family help, ending with the patient's goals in their words.
More guidance
Record the demands the treatment has to meet: job tasks and hours, the commute (riding a two-wheeler, standing in a crowded train), sport, and household roles. Ask about floor sitting, squatting, the type of toilet at home and the number of stairs, because these often decide what a functional goal looks like for this patient. Note who lives at home and who could help with exercises. Close with the patient's goals in their own words.
Safety Screening
Every red-flag question asked, each answer including the negatives, and any action taken.
More guidance
Ask every red-flag question your clinic's policy lists and record each answer, including the negatives. 'Red flags nil' with nothing behind it is hard to stand behind if the picture changes later. For any positive answer, write what was asked, what the patient said, and what you did under the clinic's onward-referral policy: who you informed, how and when. The form records that the screen happened and what followed. It does not grade risk or replace medical review.
Observation and posture
What you see, such as posture, swelling, scars, gait and aids, with measurements over labels.
More guidance
Describe what you see before deciding what it means. Cover standing and sitting posture, swelling, wasting, scars, skin and colour changes, the general pattern of walking, and any aids. For neuro patients add the resting position of the limbs and any involuntary movement. Measurements carry further than labels: a girth at a stated landmark is more useful than 'mild swelling', and a photograph, where the clinic's consent policy allows it, is clearer still.
Range of Motion
Active and passive range with units, position and method, and where pain starts.
More guidance
Record active and passive range where you tested both, with units, patient position and method: goniometer, inclinometer, tape measure or visual estimate. Note where pain begins in the range. Measure the other side when it is a fair comparison. When you re-measure, repeat the same position and landmarks; most changes that cannot be reproduced at the next visit come from a change of method rather than a change in the patient.
Strength
Each strength result with its method, test position, any substitution and any pain.
More guidance
Fill the Method column every time. It might be the grading system your clinic uses, a handheld dynamometer reading, repetitions completed through full range, or a timed functional task with the chair height recorded. Note the test position, any substitution you saw, and whether testing was painful. A weak, painful contraction and a weak, painless one usually lead to different plans, so the difference belongs on the page.
Neurological findings, special tests and palpation
Only the neuro checks and special tests you did, each with its side and finding.
More guidance
Record only the neurological checks you actually performed, such as sensation by area, reflexes, myotomes, tone or coordination, and leave out what you did not test. For special tests, name each test, the side, and what you observed, rather than writing 'positive' alone. For palpation, name the structure and the finding: tenderness, warmth, swelling or spasm. Save the interpretation for the Assessment section.
Function
Each activity's current level, the help or aids needed, and conditions such as distance.
More guidance
This table turns findings into what the patient can and cannot do. For each activity record the current level, the help and aids needed, and the conditions: surface, height, distance or time. Add rows that matter to this patient, such as getting up from the floor, squatting, boarding a bus or lifting a toddler. If your clinic uses an outcome measure, record its name and the result as its manual reports it.
Assessment
Your clinical reasoning, linking key findings to a short, numbered problem list.
More guidance
This section is the physiotherapist's clinical reasoning in your own words, so the page gives guidance only. Connect each important finding to the problem it supports, state your working view of the main contributing factors as your clinic's practice allows, and say what is still uncertain or needs another opinion. Medical conditions belong to the referring doctor's documentation: quote them as written rather than restating them as your own finding. Then keep the problem list short, functional and numbered so each goal can point back to it.
Goals
Each goal tied to a numbered problem, with baseline, measurable target, conditions and date.
More guidance
Write each goal against a numbered problem, with today's baseline, a measurable target, the conditions, and a date. Keep short-term goals for the next few weeks separate from the longer goal the patient actually cares about. A quick test before you finish: could another physiotherapist check this goal in two minutes without asking what you meant?
Treatment Plan
Planned interventions, frequency, episode length, home exercises given, and the re-assessment session.
More guidance
List the interventions you plan, with parameters where they are already decided, the session frequency and the expected length of the episode, the home exercises given today, and the session at which you will re-assess. Write the advice you gave in the words you used, because patients repeat it to their families. If the plan depends on something outside physiotherapy, such as a surgeon's review or an investigation the doctor has ordered, say so.

Physiotherapy assessment format and form, with sample entries: filled sample

Fictional entries, initials only, showing the level of detail to aim for. Impression and summary sections are left for the treating clinician.

Subjective

R., 46, reports right-sided low back pain for 3 weeks after lifting a gas cylinder at home. Worst in the first 4 days. Back at office work since week 2 but cannot sit beyond 30 minutes. Has taken tablets prescribed by his GP. No previous physiotherapy for this episode.

Pain

Right buttock, deep ache. On the clinic's 0–10 scale: 3 at best (lying down), 7 at worst (after 30 minutes sitting). Eases within 10 minutes of walking. Morning stiffness about 15 minutes. Wakes once a night on turning; settles on changing position.

Social history, occupation and patient goals

Bank cashier, seated about 7 hours with one break. Rides a two-wheeler 40 minutes each way. Lives with wife and parents on the second floor, no lift. Goal in his words: 'to sit through a full working day and play cricket with my son on Sundays.'

Safety Screening

Asked about bladder or bowel change, numbness in the groin, unexplained weight loss, fever, night pain not eased by any position, and any history of cancer: all answered no. Advised to contact the clinic at once if new numbness or bladder change develops.

Observation and posture

S., 63, five weeks after left knee replacement. Walks with a cane in the right hand; reduced knee bend on the left during swing. Healed vertical scar over the left knee, no redness. Girth 5 cm above the patella: left 41 cm, right 39 cm.

Range of Motion

Left knee flexion, supine, goniometer: active 95°, passive 100°, pain at end of range. Right knee flexion active 130°. Left knee extension lacks 5° actively and passively.

Strength

Hip abduction, side-lying: right completes 15 repetitions through full range; left 8 before hip hitching appears. Sit to stand from a 45 cm chair without arms: 5 repetitions in 18 seconds, hands on thighs from the third repetition.

Neurological findings, special tests and palpation

Light touch reduced over the outer left lower leg compared with the right. Knee and ankle reflexes present and equal. Straight leg raise: left stopped at about 45° with reproduction of buttock and thigh pain; right reached about 80° without symptoms.

Function

Floor to stand: holds a low stool, takes about 10 seconds. Stairs: 14 steps to her flat, one at a time with the rail, rests once halfway. Walks about 200 m on a level road before stopping because of knee pain.

Goals

By 4 weeks, S. will climb the 14 practice stairs in clinic step over step with one rail, without resting. By 6 weeks, R. will sit for 60 minutes at work with pain no higher than 3 on his 0–10 scale, as recorded in his diary.

Treatment Plan

Two sessions a week for 4 weeks, then review. Today: advice on sitting breaks every 30 minutes; 3 home exercises taught and checked, printed sheet given. Re-assess knee range and stair climbing at session 6.

Musculoskeletal and neuro assessments: what changes on the form

Section	Musculoskeletal patient	Neurological patient
Subjective	Mechanism of injury, aggravating and easing factors, work and sport demands	Onset and course since the event, falls, the carer's account, level of independence before
Objective focus	Joint range, muscle strength, special tests, palpation	Tone, sensation, coordination, sitting and standing balance, quality of movement on each side
Function table	Activities that bring on symptoms: sitting, lifting, stairs, squatting	Bed mobility, transfers, balance, walking with or without aids
What to record	Range in degrees, repetitions, timed tasks, pain on the named scale	Level of assistance, distance and time walked, the clinic's outcome measure and its result
Goals	Return to a named task with a range or pain target	Safer, more independent transfers and walking, with a carer goal where needed

Tips and mistakes to avoid

Do

Print the red-flag questions on the form rather than relying on memory at the end of a long OPD list.
Record the family's languages and who interpreted, then check the patient understood advice relayed in Tamil or Marathi.
Write the method beside every number, such as goniometer or visual estimate, so re-assessment can repeat today's conditions.
On home visits, note cot height, toilet type, entrance steps and walking space; they shape realistic goals.
If a section does not apply, write one line saying so rather than deleting the heading.
When an intern assesses, check the key findings yourself and add a supervisor row before countersigning.

Avoid

Writing 'ROM reduced' or 'power decreased' with no number, side, method or position.
Ticking 'red flags nil' without recording which questions were actually asked.
Copying the referral letter's medical condition into the Assessment section as your own finding.
Goals in therapy language, such as 'improve quadriceps strength', with no link to what the patient wants.
Ending with 'continue physio' and no frequency, expected duration or re-assessment date.

About this assessment report

A physiotherapy assessment format is the structured record of a patient's first visit: subjective history, pain, red-flag screening, objective findings such as range of motion, strength and function, a problem list, goals and a treatment plan. This free form follows that order, suits musculoskeletal and neuro patients, and fills in online or downloads as a PDF.

First visit of a new MSK, neuro or post-operative patient
A returning patient with a new complaint
Interns presenting a case to their supervisor
Replacing an old paper case format clinic-wide

Many departments still hand new graduates a photocopied case format with blurred headings. This form gives one clean structure for the first visit: what the patient tells you, what you find, how you reason about it, and your plan.

The treating physiotherapist writes it at the first visit, and a supervisor countersigns when an intern assesses. It is structure only: you choose the tests and scales, record their names and results, and the clinical reasoning stays yours.

Questions

What should a physiotherapy assessment form include?

Patient details, subjective history, pain, red-flag screening, objective findings (observation, range, strength, neurological findings, special tests, function), your assessment with a numbered problem list, measurable goals, and a treatment plan with a re-assessment date. Each is a heading on this form.

Is there a filled sample of this assessment format?

Yes. Each section in the guide above shows a fictional sample entry, using initials only. The Assessment section has guidance but no sample, because the clinical reasoning and problem list are yours to write.

Can I download this physiotherapy assessment form as a PDF?

Yes. Fill it in on screen and download the completed PDF, or download it blank and print copies. There is no sign-up, and your draft stays in your browser. Clinics using healhab can also build it as their own template in Template Studio.

Is this the same as a physical therapy initial evaluation?

Broadly, yes. US clinics say initial evaluation and often add payer-specific sections; Indian and UK clinics say physiotherapy assessment. The clinical content is the same, so add any fields your referrers or insurers ask for.

Can I use it for neuro and paediatric patients?

Yes, with some adjustment. For neuro patients, spend more of the form on tone, balance and transfers. For children, record who gave the history, add play and school activities to the function table, and use your clinic's chosen paediatric measures.

How is the assessment form different from a physiotherapy case sheet?

The case sheet is the intake record: details, complaint, history, screening and goals. The assessment form adds the examination, reasoning, goals and plan. Many Indian clinics combine them into one case format; use our separate case sheet if you prefer them apart.

Does the form tell me which tests to do or how to grade them?

No. It has no test items, grading or interpretation. Choose the tests and outcome measures your clinic uses, write their names, and record each result as the test's manual reports it.

More physiotherapy templates

Assessment report formats for other therapies

Write every report inside your clinic system.

Keep these as your clinic's own templates, write from reviewed session notes, publish branded PDFs, and keep families updated.

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