Free Editable Ortho/MSK Physiotherapy Assessment Sheet

1

Patient Information

Full Name

Age

Sex

Date of Assessment

File / ID No.

Occupation

Dominant Side

Referred By

Contact Number

2

Subjective Assessment

History

Chief Complaint

History of Present Illness (onset, mechanism of injury, progression)

Pain Assessment — Body Chart

Anterior (Front)

Posterior (Back)

Pain Severity (NPRS / VAS)

No pain level selected

Pain Characteristics

Aggravating Factors

Easing / Relieving Factors

24-Hour Pattern (morning stiffness, night pain, etc.)

Screening & Background

Past Medical History

Past Surgical History

Current Medications

Relevant Investigations

Red Flag Screening

Unexplained weight loss Night pain unrelieved by rest Fever / unwell History of cancer Saddle anesthesia Bladder / bowel changes Significant recent trauma None reported

Patient's Goals / Functional Expectations

3

Objective Assessment

Observation

Posture (static)

Gait

Swelling / Deformity / Muscle Wasting

Skin / Other Visible Changes

Palpation

Tenderness (site & grade)

Swelling / Effusion

Temperature

Muscle Spasm / Guarding

Range of Motion (ROM)

Joint / Movement	AROM (R)	AROM (L)	PROM (R)	PROM (L)	Notes (pain / end-feel)

Manual Muscle Testing (MMT)

Grading: 0 = No contraction · 1 = Trace · 2 = Poor (gravity eliminated) · 3 = Fair (against gravity) · 4 = Good (against resistance) · 5 = Normal

Muscle / Muscle Group	Grade (R)	Grade (L)	Pain on Resistance	Notes

Special Orthopedic Tests

Test	Right	Left	Notes
Neer's Test
Lachman Test
SLR (Straight Leg Raise)

Neurological Screening

Level	Reflex (R)	Reflex (L)	Power (R)	Power (L)	Sensation (R)	Sensation (L)
C5/C6
L4/L5
S1

Other Objective Findings

4

Clinical Impression / Assessment

Working Diagnosis / Clinical Impression

Impairments

Activity Limitations

Participation Restrictions

Clinical Reasoning / Notes

5

Treatment Plan

Short-Term Goals

Long-Term Goals

Planned Interventions

Manual therapy Therapeutic exercise Electrotherapy / modalities Taping / bracing Postural correction Patient education Home exercise program Gait / balance training Other

Frequency & Duration

Next Review Date

Home Exercise Program Prescribed

Precautions / Contraindications

6

Sign-off

Treating Physiotherapist — Signature & Date

Patient Signature (consent to treatment) & Date

Follow-up / Next Appointment