Physiotherapy Assessment Form
Physiotherapy Assessment Form
Please fill out this form completely to provide a thorough assessment of your condition for physiotherapy evaluation.
Personal Information
Name
Date of Birth
Address
Phone number
Medical History
Do you have any current medical conditions? (Please list)
Have you had any previous injuries or surgeries? (Please describe)
Are you currently taking any medications? (Please list)
Assessment of Symptoms
Describe the issue or symptoms you are experiencing
How long have you been experiencing these symptoms?
On a scale of 1 to 10, how would you rate your pain or discomfort?
Physical Assessment
Type a Please check any of the following that apply to you:?
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Back pain
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Neck Pain
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Shoulder Pain
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Joint Stiffness
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Muscle Weakness
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Signature
By signing this form, I confirm that the information provided is accurate and complete to the best of my knowledge.
Name:
Date:
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