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  • Assessment Form

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    Vishal Patle
    4K views2 pages
    This document contains a patient intake form collecting personal information such as name, age, contact details, medical history, and details of the current condition or injury. It collects information on vital signs, symptoms, pain levels, factors that improve or worsen the condition, goals for therapy, and other relevant medical information. The form is to be completed by a physiotherapist for a new patient and includes sections for personal details, history, present medical history, injury details, therapy history and goals.

    Original Description:

    Physiotherapy Assessment format

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    This document contains a patient intake form collecting personal information such as name, age, contact details, medical history, and details of the current condition or injury. It collects information on vital signs, symptoms, pain levels, factors that improve or worsen the condition, goals for therapy, and other relevant medical information. The form is to be completed by a physiotherapist for a new patient and includes sections for personal details, history, present medical history, injury details, therapy history and goals.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPTX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    4K views2 pages

    Assessment Form

    Uploaded by

    Vishal Patle
    This document contains a patient intake form collecting personal information such as name, age, contact details, medical history, and details of the current condition or injury. It collects information on vital signs, symptoms, pain levels, factors that improve or worsen the condition, goals for therapy, and other relevant medical information. The form is to be completed by a physiotherapist for a new patient and includes sections for personal details, history, present medical history, injury details, therapy history and goals.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPTX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
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    Name: _____________________________________ Age: _______ Sex: ________ Occupation: ____________


    Height: _________ Weight: ________ Phone: ___________________ Email: ____________________________
    Address: ___________________________________________________________________________________
    Employer/Insurer: __________________________ Referred by: _____________________________________
    Diagnosis on Referral: ____________________________________
    Family History: ______________________________________________________________________________
    Medical History: _____________________________________________________________________________
    ___________________________________________________________________________________________

    Present Medical History: _____________________________________________________________________


    ___________________________________________________________________________________________

    Date of Injury __________ Date of Surgery __________ Type of Surgery: ______________________________


    Chief Complaint/Ailment/Injury: _______________________________________________________________
    ___________________________________________________________________________________________

    Vital Signs:

    BP:
    HR:
    Temp:

    mmHg
    bpm

    Briefly describe how you were injured:


    __________________________________________________________________________________________
    __________________________________________________________________________________________
    Have you received therapy for this condition? O Yes
    How many visits? _________________________
    Has your condition been getting:
    O Worse
    Are your Symptoms:
    O Constant
    or

    O No
    O Same
    O Intermittent

    When? _________________
    O Better

    Mark the number that best corresponds to your pain:


    O 0 O 1 O 2 O 3 O 4 O 5 O 6 O 7 O 8 O 9 O 10 (Excruciating pain)

    What decreases/makes your condition better? (Mark all that apply)


    Rest
    Bending
    Movement
    Heat
    Sitting
    Standing
    Ice
    Rising
    Walking
    Medication
    Changing positions
    Lying

    Better in AM
    Better as day progress
    Better in PM
    Others: _______________

    What increases/makes your condition worse? (Mark all that apply)


    Rest
    Bending
    Movement
    Stairs
    Sitting
    Standing
    Cough
    Rising
    Walking
    Sneeze
    Prolonged positioning
    Lying

    Worse in AM
    Worse in PM
    Deep breath
    Others: _______________

    What are your goals to be achieved by the end of therapy?


    __________________________________________________________________________________________
    __________________________________________________________________________________________
    Medical Information (Mark all that apply)
    Difficulty in swallowing
    Motion Sickness
    Arthritis
    Fever/chills/sweats
    High blood pressure
    Unexplained wt loss
    Heart trouble
    Blood clot
    Pacemaker
    Shortness of Breath
    Epilepsy/seizures
    History of smoking
    History of drug abuse
    Diabetes
    Myofascial Pain
    Fibromyalgia

    Stroke
    Cancer
    Osteoporosis
    Others: _______________
    Anemia
    Bleeding problem
    HIV/Hepatitis
    History of alcohol abuse
    Depression/anxiety
    Pregnancy

    Previous Surgeries:
    __________________________________________________________________________________________
    Other:
    __________________________________________________________________________________________
    Medication:
    __________________________________________________________________________________________

    Allergies:
    __________________________________________________________________________________________

    Physiotherapist Name/Signature

    Date

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