A free physiotherapy case sheet format for the first visit, with sample entries from the complaint to the patient's goals.
✓Front desk and physio fill together
✓Editable red-flag question list
✓Pairs with the assessment format
Free · No sign-up · Saves in your browser
What's inside
Presenting Complaint
History of Present Condition
Pain
Red-flag Screening
Past Medical and Surgical History
Occupation, Activity and Home
Patient Goals
Consent
+ 1 more sections
Preview · 9 sections
Physiotherapy Case Sheet
Name
Case number / UHID
Age / Date of birth
Sex
Phone
Alternate contact (relation)
Address
Languages spoken at home
Referred by
Date of first visit
Occupation
Dominant hand
Presenting Complaint
Main complaint in the patient's words
Onset and duration
How it started or mechanism of injury
History of Present Condition
Course since onset
Treatment already tried and its effectMedicines, injections, previous physiotherapy, massage, home remedies.
Investigations brought by the patientList each report with its date and who ordered it; do not interpret here.
Pain
Site
Type / Description
Rating (scale named)
Worse With
Better With
Night / Morning Pattern
Red-flag Screening
Question
Yes / No
Details and Action Taken
Unexplained weight loss recently?
Fever, chills or feeling generally unwell?
Any history of cancer?
Pain at night that does not ease in any position?
Recent significant fall or injury?
New numbness in the groin or inner thighs?
New change in bladder or bowel control?
Numbness, tingling or weakness in arms or legs that is getting worse?
Long-term steroid medicine?
Dizziness, blackouts, double vision, or difficulty speaking or swallowing?
Other questions the clinic's policy lists
Action taken under the clinic's referral policy
Past Medical and Surgical History
Condition / Surgery
Yes / No / Not Known
Year
Current Treatment
Diabetes
High blood pressure
Heart or lung condition
Thyroid condition
Fracture or thinning of bones
Previous surgery
Other
Current medicines
Allergies
Occupation, Activity and Home
Work demands
Daily activity, exercise and sport
Home set-upStairs, floor sitting, toilet type, bed or cot, who lives at home and who can help.
Patient Goals
What the patient wants to get back to
Consent
Consent for assessment and treatmentHow consent was obtained and by whom, under the clinic's consent policy.
Therapist Sign-off
Therapist
Designation
Registration
Date
How to fill it in
1
Patient details
Every label, an alternate contact with relation, home languages, occupation and dominant hand.
More guidance
Fill every label, and record an alternate contact with their relation, since many patients are brought by family. Note the languages spoken at home and the one the patient prefers for exercise instructions. Occupation and dominant hand go here because they shape the rest of the history. Use the clinic's case number or the hospital UHID so records join up across visits.
2
Presenting Complaint
The complaint in the patient's words, its onset, duration, and how it started.
More guidance
Write the main complaint in the patient's own words first, then whether it began suddenly or gradually, how long ago, and how it started. If there was an injury, record the mechanism in enough detail to picture it. Patients often arrive with several complaints; list them all and ask which one matters most.
3
History of Present Condition
How the problem has behaved, treatment tried and its effect, and reports brought.
More guidance
Record how the problem has behaved since it began and what has already been tried: medicines, injections, earlier physiotherapy, massage, oils or other home remedies, and the effect of each. Ask about traditional treatments without judgement, because patients often leave them out unless asked. List every investigation report the patient brings, with its date and who ordered it, and leave interpretation for the assessment.
4
Pain
One row per painful area, with the named scale, what worsens or eases it, and timing.
More guidance
Use a row for each painful area. Write the name of the scale you use with every rating so later notes use the same one. Record what makes the pain worse and better as specific activities, and whether it is worse at night or in the morning; that pattern also informs the screening questions that follow.
5
Red-flag Screening
Each question asked by the physiotherapist, answered yes or no, with details and action.
More guidance
The physiotherapist asks each question and records yes or no, with details for every yes. The list in the template is a starting point; edit it to match your clinic's screening policy and the patients you see. A yes is not graded on this sheet. It triggers whatever action your clinic's referral policy sets, and you record that action, who was told and when.
6
Past Medical and Surgical History
Each listed condition as reported, with year and treatment, plus medicines and allergies.
More guidance
Ask about each listed condition and record what the patient reports, with the year and current treatment. Write 'not known' rather than leaving a blank when the patient is unsure; a blank looks like a question that was never asked. List current medicines, including over-the-counter and traditional remedies, and any allergies.
7
Occupation, Activity and Home
The physical demands of work and daily life, and the home set-up.
More guidance
Record the physical demands of work and daily life: hours seated or standing, lifting, travel, sport, household work, and caring roles such as lifting a grandchild. Then ask about the home: stairs, floor sitting, squatting, the type of toilet, where the patient sleeps, and who lives there. These details turn generic goals into ones that fit the patient's life.
8
Patient Goals
What the patient wants to do again, in their own words.
More guidance
Ask what the patient wants to be able to do again and write it in their words. One or two goals are enough at this stage. You will turn them into measurable goals in the assessment and treatment plan.
9
Consent
How consent was obtained and by whom, under your clinic's consent policy.
More guidance
Record how consent for assessment and treatment was obtained and by whom, following your clinic's consent policy. If a family member gave consent on the patient's behalf, record their relation and the reason.
Physiotherapy case sheet format and sample: filled sample
Fictional entries, initials only, showing the level of detail to aim for. Impression and summary sections are left for the treating clinician.
Patient details
Alternate contact: son, V. Languages: Kannada at home, some Hindi and English. Prefers instructions in Kannada. Right-handed.
Presenting Complaint
'Pain in my right shoulder when I comb my hair.' Gradual onset over 2 months; no injury remembered. Worse since she began hanging washing on a high line.
History of Present Condition
Tablets prescribed by a local doctor for 10 days with partial relief. Oil massage at home for 3 weeks with no change. Brought an X-ray report of the right shoulder dated 2 September.
Pain
Right shoulder, front and side. Sharp on movement, dull ache at rest. 6 at worst on the clinic's 0–10 scale. Worse reaching overhead and lying on the right side. Better with the arm resting on a pillow.
Red-flag Screening
Night pain not eased by any position: yes, for 3 weeks. Discussed with the senior physiotherapist the same day; patient referred back to her GP with a letter, as the clinic's policy requires.
Past Medical and Surgical History
Diabetes since 2015, on tablets; last blood test 'about a month ago'. High blood pressure: no. Surgery: uterus removed in 2012.
Occupation, Activity and Home
Homemaker in a joint family of 7. Cooks standing for about 3 hours a day; sweeps and mops squatting. Ground-floor house, Indian-style toilet, sleeps on a cot.
Patient Goals
'To comb my hair and hang the washing without pain.'
Case sheet or assessment form?
Case sheet
Assessment form
Covers
Who the patient is, the complaint, history, screening and goals
Examination findings, reasoning, problem list, goals and plan
Completed by
Front desk, patient and physiotherapist together
The treating physiotherapist
When
At registration and the start of the first visit
During and after the first examination
Red-flag questions
Asked and recorded here
Reviewed again in the safety screening section
Kept as
The first page of the patient's file
The clinical record of the initial assessment
Tips and mistakes to avoid
Do
On paper, print the case sheet double-sided on one sheet; thick files tend to lose their first page.
Keep red-flag questions with the physiotherapist, even when registration staff fill in the rest.
Record an alternate contact and relation; often a son or daughter manages appointments and payments.
Ask about massage, oils and home remedies neutrally; what was tried shapes the patient's expectations.
Clinics using healhab can build this as their own intake template in Template Studio.
Avoid
Leaving red-flag rows blank when the answer was no, so nobody can tell the questions were asked.
Writing the referral letter's condition as the presenting complaint instead of the patient's own description.
Recording 'housewife' or 'retired' without the activities the person actually does each day.
Interpreting X-ray or MRI reports on the case sheet instead of listing them with their dates.
Taking one phone number and no alternate contact.
About this case history form
A physiotherapy case sheet is the intake record opened at a patient's first visit: personal details, presenting complaint, history, pain, red-flag questions answered by the physiotherapist, past medical history, occupation, home set-up and the patient's goals. This free case sheet format can be filled in online, printed blank or downloaded as a PDF.
At the first visit, before the examination
In a busy OPD with a separate registration desk
Home-care referrals, at or before the first visit
Students recording and presenting cases
Read more
In Indian physiotherapy departments the case sheet is the first page of every file: who the patient is, why they came, and the history and screening needed before examination. US clinics call a similar page a patient intake form.
The front desk or patient can fill in personal details; the physiotherapist takes the history and always asks the red-flag questions. The assessment form then picks up with the examination, reasoning, goals and plan.
Questions
What is a physiotherapy case sheet format?+
The standard first page of a physiotherapy file: personal details, presenting complaint, history, pain, red-flag screening, past medical history, occupation and home, and the patient's goals. Print it blank or fill it in online.
Is there a filled sample of this case sheet?+
Yes. Each section in the guide above shows a fictional sample entry, initials only, and Consent has guidance. The case sheet has no impression section: your findings and reasoning belong on the assessment form.
What should a physiotherapy patient intake form include?+
Contact details with an alternate contact, home languages, the complaint in the patient's words, history and treatment so far, pain, red-flag questions asked by the physiotherapist, medical history and medicines, work and home demands, goals, and how consent was taken.
Who should fill in the case sheet?+
Reception staff or the patient can complete the personal details. The physiotherapist takes the history, asks the red-flag questions, records the action taken for any yes, and signs the sheet.
Can I change the red-flag questions?+
Yes, and you should align them with your clinic's screening and referral policy. The template's questions are a starting list. The sheet does not grade risk or decide what happens next.
Is there a printable physiotherapy case sheet PDF?+
Yes. Download the blank case sheet as a PDF to print, or fill it on screen and download the completed copy. No sign-up is needed.
Does the case sheet work for children?+
Yes, with additions. Record the parent or carer giving the history, add school and play activities, and include your clinic's birth and developmental history questions. Use the screening questions your clinic's policy sets for children.
