Templates · Free template · Physiotherapy
Physiotherapy Initial Assessment Template
A printable initial assessment for physiotherapy clinics, structured from history and red flags through examination and outcome measures to goals and a treatment plan.
The initial assessment sets the baseline
Every later note is compared with the first, so the initial assessment should record starting points precisely: pain scores, range of motion, strength, function, and a validated outcome measure. Those become your progress data.
Screen for red flags early and document the screening, even when it is negative. Then state goals with a timeframe, so that progress and discharge decisions have something to be measured against.
Physiotherapy Initial Assessment
Visit
History
Red flags
- Unexplained weight loss
- Night pain
- Bladder / bowel changes
- Saddle anaesthesia
- Progressive neurological deficit
- None identified
Examination
| Measure | Left | Right | Notes |
|---|---|---|---|
| Range of motion | |||
| Strength | |||
| Special tests | |||
| Neuro screen | |||
| Palpation |
Outcome measures
Impression and plan
Sign-off
Template from zdrovia.ca/templates/physiotherapy-initial-assessment-template/ · Adapt to your college's documentation standard before use.
Structured notes without the typing
Zdrovia's charting gives you note templates you can adapt to this one, outcome scores that trend across visits, and an AI Scribe that drafts the note from what you say in the room. Everything stays on one patient record, free for solo practitioners, with data stored in Canada.
See how Zdrovia is set up for physiotherapy clinics.
Frequently asked questions
Which outcome measure should I use?
Choose one validated for the condition, such as the Neck Disability Index or Oswestry, and repeat it on a schedule.
Should I document negative red flags?
Yes. A documented negative screen is part of the record.
Related
This template is a documentation aid, not clinical guidance. It records decisions about dosing, depth, and settings; it doesn't make them. Documentation standards vary by province and profession, so adapt it to your regulatory college's requirements.