Date:

Subjective Examination Template

Name: DOB:
Pronouns:

Pa: (pain A, pain B…)

Constant/ intermittent
Deep/ superficial
SQs (special questions)
Intensity of the pain (from 0-
10)

History of presenting condition (include MOI – mechanism of injury, how did

you injure yourself):
When did the pain start/how long has the pain been occurring?
How did you initially hurt yourself?
Did something or a movement trigger the pain?
Does this stop you from doing anything?

Aggravating Factors:
Is there anything that makes your issue worse?

Easing Factors:
Is there anything that you do that makes the pain less severe?

24 hour (AM/PM/night):
Date:

Are there times where the pain/issue is more prominent throughout the day?
Is the pain waking you up/do you get this pain at night?

Special Questions (pins and needles, numbness or radiating pain, bladder and
bowel function):
Do you have any unusual sensations such as pins and needles, numbness or
radiating pain, bladder and bowel function?
e.g. Not applicable (N/A)

Special Questions (clicking, catching, locking or giving way):

Do you ever feel any clicking, catching, locking or giving way?

Previous injury:
Have you had any other previous injuries?
If so, what did you do to fix it/is it fixed yet/did you do anything about it?

Investigations (Ix):
Have you seen anyone else about this issue?
Have you had any MRI, xray, diagnostic ultrasound, blood test?

Past History (PHx):

THREADS:
Medications:
Are you on any medication at the moment?
General Health:
Any family history with cancer/disease?
Surgical:
Have you had surgery before?
Ca:
Have you had cancer before?
Do you have a family history of cancer?
Bone Density:
Date:

Do you know what your bone density is like?

Do you have a family history of poor bone density?
Have you had any scans of your bones?
Social History (SHx):
Occupation:
What do you do for a living?
Physical activity (including normal mobility):
What do you do for exercise?
What does a normal day look like for you?
Whose house do you stay at on certain days?

Family:
Who is in your family – what support do you have/not have?
Who do you live with at home?
Do you live with anyone else?

Does your injury stop you from doing anything?

Is your independence impacted by this injury?

Psychological stress:
How are you feeling about your injury/how does your injury make you feel?
Is there anything that is causing you concern?
How is your work and home life at the moment?

Goals:

What do you want to get out of physio?

Are there any specific activities/tasks you want to be able to complete?
Date:

ICF Summary:
Body structure and function impairments:

Activity limitations:

Participation restrictions:

Contextual factors (environmental and personal):

Date:

Plans for physical examination:

Don’t worry about this