Physiotherapy Assessment Sheet
Patient Name
Date of Assessment
Age
Time of Assessment
Gender
Select Gender
Female
Male
Physiotherapist
Contact No
Contact No
Chief Complain
History of the Patient
Present History
Past History
Medical History
Allergic to
Surgical History
Environmental History
Occupational History
Family History
Vital
Pulse Rate
BP Rate
Respiratory Rate
Temperature
Diagnosis
Goals
Short Term
Long Term
Treatment Plan
Eqipmental
Manual
Home Advice
Next Visit Date
Suggested no. of Total Sitting
Neurological Assessment
Red Flags
Cancer
Bone Tumour
Acute generalised infection D
Bone Tumour
Schizophrenia
Drug Abuse
Neurological Examination
Sensory Affection
Violence
Depression
Personality Disorder
Drug Abuse
Psychological
Observation
External Aids
Edema
Gait
Posture
Body Build
Limb Attitude
Examination
Glasgow Coma Scale (GCS)
Eye Opening
Spontaneous
To Verbal Command
To Pain
No Eye Opening
Verbal Response
Oriented
Confused
In Appropriated Words
Incomprehensible Sounds
No Verbal Response
Motor Response
Obey_Commands
Localise Pain
Withdraws from Pain
Flexion Response to Pain
Extension Response to Pain
No Motor Response
Cortical
Motor
Muscle power (Grade)
Muscle Tone - Spastic
Muscle Tone - Rigid
Voluntary Control
Reflex - Superficial
Reflex - Deep
Co-ordination and balance
Finger to Finger
Finger to Nose
Balance
Bowel & Bladder Control