Physiotherapy Assessment Form
Basic Information
Full Name
Date of Birth
Email
Phone Number
Age
Height (cm)
Weight (kg)
BMI (Body Mass Index)
Physiotherapy Assessment
Physical Condition
Select an option
Sedentary
Slightly Active
Moderately Active
Very Active
Athlete
Diagnosis
Pain Location
Pain Duration
Pain Type
Select pain type
Sharp
Dull
Aching
Burning
Throbbing
Other
Pain Intensity (0 = No pain, 10 = Worst pain)
0
Pain Frequency
Select frequency
Constant
Intermittent
Occasional
Aggravating Factors
Relieving Factors
Functional Limitations
Previous Treatments
Current Medications
Impact on Daily Activities
Mobility Assessment (select all that apply)
Walking
Stairs
Balance
Transfers (e.g., bed to chair)
Other
Physiotherapy Goals
Additional Notes
Health History
Muscle Mass (%)
Goals
Comments
Submit Assessment