Physiotherapy assessment

Pain areas, intensity, and injury background to plan the physical treatment.

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Initial physiotherapy assessment

Full name*

First Name

Last Name

Date of birth

Phone number*

Where do you feel pain or discomfort?*

Neck Shoulder Upper back Lower back Hip Knee Ankle or foot Wrist or hand

How strong is the pain today?*

No pain

1 2 3 4 5 6 7 8 9 10

Worst imaginable

How does the pain behave?

It's constant It comes and goes Only with certain movements Worse in the morning

Is the pain related to an accident or injury?*

Yes No, it appeared gradually

When did it happen?

How did it happen?

Previous treatments for this issue

What activity do you want to get back to?

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