Patient Physiotherapy Assessment Form

Name:

Date of Birth:

Contact Number:

Email:

Address:

Emergency Contact:

What brings you here today?

Any past injuries or surgeries?

Any ongoing medical issues?

List any medications you take:

Do you have any allergies?

Where does it hurt?

How bad is the pain (on a scale of 1 to 10)?

How often do you feel this pain?

What makes it feel worse?

What makes it feel better?

Can you move normally?

Are you feeling strong and balanced?

Can you do everyday activities without trouble?

How bad is your pain (0 to 10)?

How often do you feel it?

What does it feel like?

How active are you normally?

What do you hope to achieve with physiotherapy?

I agree to share this information.