Physiotherapy Assessment Form

June 11, 2011

Physiotherapy assessment form is used for clinical purpose by a physiotherapist to understand if the patient requires physiotherapy or not and to know his health condition.  This type of form is filled by an individual when he or she goes for physiotherapy
Sample Physiotherapy Assessment form

Q1.  What is your name and mention your age?

________________________________________

Q2. What are the diseases you have suffered at past? Mention with details.

____________________________________________________

Q3. What medicines are you taking? Mention the purpose.

_________________________________________________________

Q4. Mention if you have any problems with your bone health. If yes, please mention since how long you are having it?

Q5. Do you have undergone any kind of surgery at the past? If yes, please mention with details when and why?

__________________________________________________

Q6. Do you have a fear of fall while walking on the floor?

Q7. Have you got physiotherapy done in the past? If yes for what reason and was it effective?

 

Download Physiotherapy Assessment Form In Word Format

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