Physiotherapy assessment form template

A free physiotherapy assessment form for a patient's first musculoskeletal visit, which you fill in on screen. The headings run in the usual order: history, red flag screening, physical examination, outcome measures, your assessment and the plan. Each one has a few short prompts underneath. Print it, or copy it as plain text into your clinic's record system. This page does not store or send anything you type.

Date Time Patient reference Age Body area

Subjective

Presenting complaint

The main problem and the reason for coming, in the patient's own words. Put exact phrases in quotation marks.
Where the symptoms are. A body chart helps you record the location, nature and extent of each one.

History of the present condition

Onset: when and how it started, and any injury or activity that set it off. How long it has lasted, and how it has changed since.
Pain and other symptoms (OLDCARTS): onset, location, duration, character, aggravating and alleviating factors, radiation, temporal pattern, severity (for example 0 to 10).
Depth and quality, abnormal sensation such as pins and needles or numbness, whether symptoms are constant or come and go, and how the areas relate to each other.
Behavior over 24 hours: how the symptoms change from morning to night.
Severity, irritability and nature: how much activity brings the symptoms on, how bad they get, and how long they take to settle.
Effect on daily activities, work, sport and sleep. Treatment so far and how it helped.
Investigations already done, such as imaging or blood tests, with the date and result.

Related: Pain scales (NPRS and VAS)

Red flag screening

A yes answer is not a diagnosis. It needs your clinical judgment, weighed with the patient's age, sex and the rest of the history and examination, and onward referral following your local pathways where your concern is raised. Suspected cauda equina syndrome, or signs of a stroke or a blood vessel problem in the neck (even if they have gone), need emergency referral straight away. Tell the patient why you are asking: some of these questions can seem to have nothing to do with their pain.

The questions come from the IFOMPT frameworks for serious spinal pathology and for the neck, so they are written for spinal problems. For other body areas, screen for the serious conditions that fit the area, such as a fracture, an infection (for example a hot, swollen joint), cancer, a blood clot in the leg, or pain referred from the heart or other organs. Past cancer, weight loss the patient cannot explain, fever and feeling generally unwell matter for every area.

Cauda equina syndrome

What we tell patients: sciatica warning signs

Pain down one or both legs, or pins and needles, numbness or weakness in the legs? Both legs at the same time?

Numbness, pins and needles or altered feeling in the inner thighs, bottom or genitals (saddle area)?

A change in passing urine: going more often, trouble starting, not being able to go, reduced feeling or leaking?

A change in bowel control or feeling, new constipation included?

A change in sexual function: getting an erection, ejaculating, or feeling in the genitals during sex?

Spinal fracture

What we tell patients: osteoporosis warning signs

A significant injury or a fall from a height, or pain that started suddenly with something minor such as a cough or a sneeze?

Osteoporosis, a previous osteoporotic or spinal fracture, or steroid tablets or inhaled steroids (dose and how long)?

Older age, or a history of falls? The framework also lists female sex as a risk factor, especially after the menopause.

Severe pain that is unfamiliar to the patient, or pain in the thoracic spine?

Spinal malignancy

What we tell patients: low back pain warning signs

A past history of cancer? Which type, and when?

Weight loss the patient cannot explain?

Night pain, pain that is severe, constant and getting worse, band-like pain, or being unable to lie flat?

Feeling generally unwell (systemically unwell)?

Spinal infection

What we tell patients: low back pain warning signs

Fever or chills? The framework notes that about half of people with a spinal infection report no fever, so a no does not rule it out.

Reduced immunity: diabetes, HIV, rheumatoid arthritis, long-term steroids or alcohol misuse?

A recent infection, spinal surgery or other invasive procedure, or intravenous drug use?

A history of TB, or contact with someone who has TB? Born in or living in a country where TB is common? In countries with a lot of TB, that last part is yes for most patients, so give more weight to TB contact, crowded living conditions, and a cough for 2 weeks or more, fever, night sweats or weight loss.

Neurological symptoms

What we tell patients: neck pain warning signs

A change in feeling in the arms or legs, or new trouble with walking, balance or coordination? Symptoms in both arms or both legs raise more concern.

Neck: blood vessel problems

What we tell patients: whiplash warning signs

Headache or neck pain that is new, or feels unusual or different from before? A sudden severe headache?

Dizziness, double vision or other visual disturbance, nausea or vomiting, unsteadiness, trouble speaking or swallowing, a drooping eyelid, facial weakness, weakness in an arm or leg, pins and needles in the face or limbs, confusion, drowsiness, blacking out, or a drop attack (the legs give way without blacking out)?

Risk factors: recent trauma, high blood pressure, smoking now or in the past, high cholesterol, migraine, a recent infection, oral contraception, a known blood vessel abnormality, or a family history of stroke?

Details of any yes answer, your reasoning and the action taken

Past medical history

Previous episodes of this problem, and other injuries, operations and illnesses.
Previous treatment, physiotherapy included, and how well it worked.
General health and long-term conditions.

Medicines and allergies

Current medicines, pain relief included, and how well they work. For steroid tablets or inhaled steroids, the dose and for how long.
Allergies to medicines, materials such as latex, foods or anything else.

Social and family history

Work and its physical demands. Physical activity level, sport and hobbies.
Living situation, and support at home.
Tobacco, alcohol and drug use.
Relevant conditions in the family.

Psychosocial factors and goals

Psychological and social factors that can slow recovery (yellow flags), such as fear of movement, worry or low mood.
Work factors (blue flags), and system or contextual obstacles such as legal or financial problems (black flags).
What the patient expects from treatment.
The patient's own goals, short term and long term.

Objective

Consent to the physical examination

Explain what you will examine and why before you start, and record the patient's consent.

Observation and palpation

Posture, gait and how the patient moves, from the moment they come in.
With the area uncovered: bruising, redness, swelling, skin changes, muscle wasting, asymmetry or deformity.
Palpation: tenderness, swelling, warmth, muscle tone and abnormal sensation.

Range of motion

Active range, then passive range, compared with the other side.
Measure it, for example with a goniometer, and note what limits it: pain, guarding, weakness or stiffness.
Whether a movement brings on the patient's familiar symptoms. Joint stability or excess movement where relevant.

Strength

Grade each muscle group you test, for example on the MRC 0 to 5 scale, and compare sides.
A dynamometer or a repetition test gives a number you can retest. Add endurance and flexibility where relevant.

Neurological screen

Myotomes, dermatomes (light touch, pinprick) and reflexes, left and right, when symptoms spread into a limb, there is pins and needles, numbness or weakness, or the history points to the spine.
Upper motor neuron tests, such as Hoffmann's test and ankle clonus, when a spinal cord or other central problem is possible.
Gait, balance and coordination where the history suggests it.

Related: Dermatome and myotome charts

Special tests

The tests that fit your working hypotheses, such as the straight leg raise, slump or upper limb tension tests for nerve involvement.
For each test: the side, the result, and whether it brought on the familiar symptoms.

Function

A task that matters to the patient and brings on their symptoms, measured so you can retest it (the comparable or asterisk sign).
Functional tests where they fit, such as sit to stand, single leg stance, the Timed Up and Go test or the six-minute walk test, and sport or work tasks.

Outcome measures

Pain intensity, for example on the NPRS or VAS.
A questionnaire for the area and the problem, for example the Oswestry Disability Index or Roland-Morris for back pain, the Neck Disability Index, the Lower Extremity Functional Scale, KOOS or WOMAC for the knee, or DASH for the arm, and the Patient-Specific Functional Scale.
The score and the date, so you can compare at reassessment.

Related: Pain scales with MCID values

Assessment and plan

Assessment

Your clinical reasoning: what the history and examination mean when read together.
Working diagnosis and other possibilities. The most likely worst case, and how confident you are that it is not present.
Irritability, and the likely pain mechanism: nociceptive, neuropathic or nociplastic.
The main problems in order of importance, linked to what the patient cannot do.

Plan

Goals agreed with the patient, in measurable terms, short and long term.
Treatment today and the home exercise program with its dose.
Education: the diagnosis, the likely time frame, what to do and what to avoid.
How often and for how long you will see the patient, and when you will reassess.
Referrals and letters to other clinicians.
Safety netting: which symptoms to watch for, what to do if they get worse, and how quickly.

Clinician name and designation

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Preview

Start typing in the form to see the assessment here.

How to use this assessment form

Check the date, and add the time if your clinic records it. For the patient, use the reference your clinic system uses, such as a clinic ID. Keep full names, dates of birth and contact details for the clinic's own record.
Take the history first, then work through the red flag questions. Set each one to No or Yes as you ask it, and leave the ones you did not ask as Not asked, so the record shows what was covered.
Record the patient's consent before the physical examination. The prompts are reminders, not a checklist: examine what the history points to, and leave out what does not apply.
Write your assessment and the plan you agreed with the patient, then add your full name and designation.
Press Print the assessment, or Copy as text and paste it into your record system. The printout shows only the assessment, without the prompts or the rest of this page.

For follow-up visits, the physiotherapy SOAP note template uses the same approach in a shorter form, and our guide on how to write SOAP notes in physiotherapy explains what makes a note clear to the next reader.

Worked example: a made-up initial assessment

This example is invented. Everything in it, the patient included, is made up to show how a finished assessment reads. It does not describe a real person, and the doses show how to write a plan, not what to prescribe.

Patient: Made-up example, not a real patient. Age 38. Body area: Low back.

Presenting complaint

"My back locked when I lifted a box at work and it hasn't been right since."
Pain across the low back, worse on the right. No pain, pins and needles or numbness in either leg.

History of the present condition

Started 10 days ago lifting a box from the floor at work. Sudden pain, could not stand up straight for about an hour. Slowly improving since day 3.
Deep ache across the low back with a sharp catch on bending. Pain 6/10 at worst when bending forward, 2/10 at rest.
Worse: bending, sitting more than 30 minutes, getting out of the car. Easier: walking, lying on the back with the knees bent, heat.
Stiff for about 20 minutes in the morning, easing once moving. Sleeps through the night.
Irritability moderate: bending brings on sharp pain at once, and it settles within about 5 minutes.
Off work for 2 days, now on light duties. Paracetamol helps a little. No imaging or blood tests.

Red flag screening

All questions for cauda equina syndrome, spinal fracture, spinal malignancy, spinal infection and neurological symptoms: no.
Explained why these questions are asked. All answered no. Neck blood vessel questions not asked: low back problem only, no neck symptoms or headache.

Past medical history

One similar episode 5 years ago that settled in 2 weeks without treatment.
No operations. No long-term conditions.

Medicines and allergies

Paracetamol when needed. No other medicines, no steroids.
No known allergies.

Social and family history

Warehouse supervisor: lifting and long periods standing.
Walks 30 minutes most days. Plays badminton once a week, stopped since the injury.
Lives with a partner.
Non-smoker. A few drinks at weekends.

Psychosocial factors and goals

Worried the back is "damaged" and that lifting will make it worse. Asked whether a scan is needed.
Expects exercises and advice.
Goals: back to full duties within 3 weeks, and badminton within 6 weeks.

Observation and palpation

Consent to the physical examination: given.

Slow getting up from the chair. Walks without a limp.
Standing: no visible shift, swelling or bruising.
Muscles beside the spine feel tight on the right. Tender to the right of the low back. No tenderness over the bony middle of the spine.

Range of motion

Bending forward: fingertips to mid-shin, familiar sharp pain at the end of range, 5/10.
Bending backward: reduced by about half, stiff, pain 3/10.
Side bending: left full, right slightly less and pulls on the right.
Hips: full range both sides, no back pain.

Strength

Hip and knee muscle groups 5/5 both sides (MRC).
Glute bridge: 10 repetitions, back pain 2/10.

Neurological screen

Myotomes L2 to S1: normal both sides.
Light touch, L2 to S1 dermatomes: normal both sides.
Knee and ankle reflexes: present and equal.

Special tests

Straight leg raise, both sides: no leg symptoms, back pulls at the end of range. Not the familiar pain.
Slump test not done: no leg symptoms.

Function

Sit to stand from a standard chair without using the hands: 5 times, pain 3/10 on the first two.
Lifting a 5 kg (11 lb) box from knee height: able, guarded, pain 4/10. This is the retest measure.

Outcome measures

NPRS: 6/10 at worst in the last 24 hours, 2/10 at best.
Oswestry Disability Index: 32%.
Patient-Specific Functional Scale: lifting boxes at work 3/10, sitting for 30 minutes 5/10, badminton 0/10.

Assessment

Working diagnosis: non-specific low back pain after a lifting strain, improving. Pain on bending forward and backward, no leg symptoms and a normal neurological screen fit a mechanical problem.
Worst case considered: serious spinal pathology. All back red flag questions answered no, no tenderness over the bony middle of the spine, no general illness. Not suspected today.
Irritability moderate. Pain mechanism mainly nociceptive.
Main problems, in order: pain and worry when bending and lifting, reduced bending range, and sitting tolerance of 30 minutes.

Plan

Goals agreed: sit for 60 minutes at work within 2 weeks, and lift a 10 kg (22 lb) box from the floor with pain no higher than 3/10 within 3 weeks.
Education: explained the working diagnosis, and that NICE advises against routine imaging for low back pain outside specialist care. Staying active and building up lifting gradually.
Home program sent to the patient's phone: cat-camel stretch, 10 slow cycles twice a day. Knee to chest stretch, 3 holds of 20 s each leg twice a day. Glute bridge, 2 sets of 10 once a day. Brisk walking, 20 minutes on most days.
Light duties at work for 1 more week, with a break from sitting every 30 minutes.
Review in 1 week: recheck bending range, the box lift and the Patient-Specific Functional Scale.
Safety netting: call emergency services or go to an emergency department straight away for numbness or altered feeling around the genitals or bottom, new trouble with the bladder or bowels, a new change in sexual function, pain, tingling, numbness or weakness in both legs, or loss of feeling in one leg. Call emergency services for back pain with chest pain. Get medical advice the same day for a leg or foot that is getting weaker (emergency department if it is getting worse by the hour), a fever or feeling hot, cold, shivery or generally unwell, weight loss without trying, or severe pain that comes on suddenly or gets worse quickly. See a doctor within a few days for pain that is worse at night or does not ease at all with rest. Low back pain page sent, with the full list.

Press Fill in the made-up example to load it into the form and see how it prints. The patient reference then reads "Made-up example, not a real patient", so a printout cannot pass for a real record. Each exercise in the plan has its own page: cat-camel stretch, knee to chest stretch, glute bridge and brisk walking. The warning signs in the safety net come from the low back pain page, which lists them all.

Red flag screening: what a yes answer means

The red flag questions follow the International Framework for Red Flags for Potential Serious Spinal Pathologies, led by the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) and published by Finucane and colleagues in 2020. It covers four conditions: cauda equina syndrome, spinal fracture, spinal malignancy and spinal infection. The questions here are shortened from the further questions in its tables.

The framework is frank about the evidence. Most red flags used in practice have little evidence behind them, and few are informative on their own. They work best as part of a thorough history and physical examination. The framework asks you to weigh them against the person's own profile, such as age and sex, to decide your level of concern. Then you choose a clinical action and follow your local pathways for emergency or urgent referral.

On our patient pages, signs of cauda equina syndrome mean calling emergency services or going to an emergency department straight away, and any sign of a stroke, even if it goes away, means calling emergency services straight away. In the clinic, the framework advises an emergency MRI and a surgical opinion when you suspect cauda equina syndrome, and the cervical framework advises referral for immediate medical investigation when your history and examination suggest a blood vessel problem in the neck. Each group of questions links to the condition page that lists what we tell patients, so your safety net advice can match it.

The neck questions are based on the International IFOMPT Cervical Framework by Rushton and colleagues, on blood vessel problems in the neck that can look like a musculoskeletal problem. It lists the risk factors and the symptoms and signs reported in these events, and warns that having no risk factors does not rule one out. Drop attacks are not in its tables: they are added to match the stroke warning on our patient pages.

Finucane and colleagues also define safety netting: advice on the signs and symptoms to look out for, what to do if symptoms get worse, and how quickly to act. The Plan section prompts for it.

Where the other headings and prompts come from

The order and most of the prompts follow Physiopedia's page on the patient clinical history. For the history, it covers the presenting condition in the patient's own words with a body chart, and how the symptoms behave over 24 hours. It also covers severity, irritability and nature, the past, medication and social history, and yellow, blue and black flags. For the examination it lists observation, palpation, joint and muscle assessment, the neurological assessment, functional tests, special tests and outcome measures. A treatment plan comes last.

Physiopedia's general physiotherapy assessment page adds the most likely worst case and how confident you are that it is not present, the asterisk sign you can retest, when to test myotomes, sensation and reflexes, and the pain mechanism. The OLDCARTS pain questions are from the StatPearls chapter on SOAP notes by Podder and colleagues.

The StatPearls chapter on the musculoskeletal examination, by Vilella and Reddivari, describes active and passive range compared with the other side and measured with a goniometer. It covers what limits a movement, and grading strength on the MRC scale or measuring it with a dynamometer. To track outcomes, it names questionnaires such as the Oswestry, Roland Morris and DASH.

This form is for a first visit. If your clinic, insurer or regulator uses its own assessment form, follow that. The Chartered Society of Physiotherapy (CSP) says records are legal documents that can be called upon in a variety of situations. It also says a good record lets an independent reader understand what was said, how far the examination went, what treatment was given and the clinical reasoning behind it.

Privacy: nothing is stored or sent

This page does not save what you type, in the browser or anywhere else, and it does not send it to PocketPhysio or anyone else. Reload the page and the assessment is gone, so print it or copy it first.

An assessment is a patient record, so treat every copy of it that way, printed or on screen.

Do not type or paste names, dates of birth, phone numbers or other details that identify a patient on a shared or public computer.
Copy as text puts the assessment on your device's clipboard, where other apps on that device can read it. If clipboard history or clipboard sharing between devices is turned on, a copy can stay there, or reach your other devices, after you copy something else.
Browser extensions that are allowed to read the pages you visit can read what you type here too.
The official record belongs in your clinic's record system. Follow your clinic's policies and the data protection and health records law where you work.
The CSP advises that electronic devices used for records are password protected.

Sources

Finucane LM, Downie A, Mercer C, et al. International Framework for Red Flags for Potential Serious Spinal Pathologies. J Orthop Sports Phys Ther. 2020;50(7):350-372. doi:10.2519/jospt.2020.9971
Rushton A, Carlesso LC, Flynn T, et al. International Framework for Examination of the Cervical Region for Potential of Vascular Pathologies of the Neck Prior to Musculoskeletal Intervention: International IFOMPT Cervical Framework. J Orthop Sports Phys Ther. 2023;53(1):7-22. doi:10.2519/jospt.2022.11147
Physiopedia. Patient Clinical History. physio-pedia.com/Patient_Clinical_History
Physiopedia. General Physiotherapy Assessment. physio-pedia.com/General_Physiotherapy_Assessment
Vilella RC, Reddivari AKR. Musculoskeletal Examination. In: StatPearls. Treasure Island (FL): StatPearls Publishing; updated 4 September 2023. NBK551505
Podder V, Lew V, Ghassemzadeh S. SOAP Notes. In: StatPearls. Treasure Island (FL): StatPearls Publishing; updated 28 August 2023. NBK482263
Chartered Society of Physiotherapy. Record-keeping guidance. Last reviewed 19 August 2025. CSP record-keeping guidance
Central TB Division, Ministry of Health and Family Welfare, Government of India. Guidelines for Programmatic Management of Drug Resistant TB in India 2021. National TB Elimination Programme. tbcindia.mohfw.gov.in

This template is a writing aid for clinicians. It is not a record system or a diagnostic tool, and it does not replace your clinical judgment, your clinic's records, local referral pathways or the rules of your regulator.