Physical Therapy Initial Assessment

Current Condition/Complaint:

• [Presenting complaint and symptom characteristics] (Include location, quality, intensity, radiation, timing, aggravating and easing factors.)

• [Onset and mechanism/precipitating event] (Include date or timeframe and context.)

• [Prior care and related history] (Previous therapy, surgery, or consultations for this condition.)

• [Course since onset] (Progression, stability, or fluctuations in symptoms.)

• [Functional impact and activity limitations] (Work duties, ADLs, sleep, recreation.)

• [Associated symptoms and screening] (Neurological/systemic symptoms, red flags, previous similar episodes.)

Investigations:

• [Relevant investigations and key findings] (Imaging, labs, or reports; include dates if available.)

Medical History:

• [Past medical and surgical history] (Include conditions relevant to rehabilitation.)

• [Allergies and current medications] (List with doses if pertinent.)

• [Family history and other pertinent medical context] (Only if applicable.)

Social History:

• [Occupation and job demands] (Physical requirements, ergonomics, work status.)

• [Lifestyle factors] (Tobacco, alcohol, physical activity, sleep, stress.)

• [Psychosocial considerations] (Beliefs, mood, motivation, barriers, supports.)

Patient Goals:

• Short-term goals: [Short-term goals] (Measurable targets with timeframe.)

• Long-term goals: [Long-term goals] (Return-to-activity/work, prevention; measurable and time-bound.)

Objective:

• [Observation and posture/gait] (Only if assessed.)

• [Range of motion and strength] (Include sides and degrees or grades where measured.)

• [Palpation and tissue findings] (Tenderness, tone, guarding/spasm.)

• [Neurological and special tests] (Test names and results.)

• [Outcome measures] (Pain scales, disability indices, functional tests.)

Diagnosis/Impression:

• Primary clinical impression: [Working diagnosis/region of dysfunction] (Based on subjective and objective findings.)

• Differential diagnoses: [Differential list] (If applicable.)

Treatment:

• Education: [Topics covered] (Condition, prognosis, posture/ergonomics, activity modification, self-management.)

• Manual therapy: [Hands-on techniques provided] (Areas treated, technique type, patient response.)

• Therapeutic exercise/neuromuscular training: [Exercises performed in session] (Type, dosage, cues, tolerance.)

• Home exercise program (HEP): [Exercises and dosage] (Frequency, sets/reps, precautions, equipment, delivery method.)

Assessment:

• [Summary of clinical reasoning and key impairments] (Link impairments to functional limitations and participation restrictions.)

• Prioritized problems: [Problem list]

• Response/progress: [Improved / stable / worsened] (Describe changes during or since session.)

• Factors influencing prognosis/plan: [Facilitators and barriers] (Risks, adherence factors, need for plan modification.)

Plan:

• [Treatment plan] (Planned interventions, progression criteria, frequency and duration of visits.)

• [Anticipated goals and expected outcomes] (Impairment-level and functional targets.)

• [Referrals/coordination of care] (If indicated.)

• [Follow-up and next session focus] (Reassessment plans, progression of exercises, education needs.)