A physiotherapy assessment template is a structured documentation framework used to systematically evaluate patients’ physical function, identify impairments, and develop treatment plans. A comprehensive physio assessment includes patient history, subjective complaints, objective measurements (ROM, strength, gait), special tests, clinical reasoning, and goal-oriented treatment planning. Below you’ll find free templates for initial evaluations, progress notes, and discharge summaries, plus guidance on using AI-powered documentation to automate your assessment notes.
Introduction
Thorough documentation is the foundation of effective physiotherapy practice. Well-structured assessment templates ensure you capture all relevant clinical findings, support evidence-based treatment decisions, meet regulatory and insurance requirements, and protect both practitioner and patient.
This guide provides ready-to-use physiotherapy assessment templates covering initial evaluations, specialized assessments, progress notes, and discharge documentation. You’ll also learn how modern AI documentation tools can streamline your assessment workflow while maintaining clinical thoroughness.
Essential Components of Physiotherapy Assessment
A comprehensive physiotherapy assessment follows the SOAP framework (Subjective, Objective, Assessment, Plan) while incorporating discipline-specific elements. Every assessment should include:
Patient Demographics and History
Patient identification information, referral source and diagnosis, medical history and comorbidities, surgical history relevant to condition, current medications, red flags and precautions, and social/occupational history affecting function.
Subjective Examination
Chief complaint in patient’s words, pain assessment using validated scales (VAS/NPRS), symptom behavior including aggravating and easing factors, 24-hour pattern and night symptoms, functional limitations and activity restrictions, patient goals and expectations, and previous treatment history.
Objective Examination
Observation and posture analysis, active and passive range of motion measurements, strength testing using MMT or dynamometry, neurological screening when indicated, special tests specific to condition, functional movement assessment, gait analysis, and palpation findings.
Clinical Reasoning and Assessment
Problem list prioritization, clinical hypothesis and differential diagnosis, contributing factors identified, prognosis statement, and contraindications and precautions noted.
Treatment Plan
Short-term and long-term goals using SMART format, proposed interventions with rationale, frequency and duration of treatment, home exercise program, patient education provided, and outcome measures selected for reassessment.
Template 1: Initial Physiotherapy Evaluation
Use for: New patient assessments, comprehensive evaluations
INITIAL PHYSIOTHERAPY EVALUATION
Patient: [Name] | DOB: [Date] | Date of Evaluation: [Date] | Therapist: [Name, Credentials]
Referral Source: ___ | Referring Diagnosis: ___ | Date of Onset: ___
MEDICAL HISTORY: Past Medical History: ___. Surgical History: ___. Medications: ___. Allergies: ___. Imaging/Diagnostics: ___.
Red Flags Screening: Unexplained weight loss: No / Yes. Night pain/sweats: No / Yes. Bowel/bladder changes: No / Yes. Saddle anesthesia: No / Yes. Progressive weakness: No / Yes. History of cancer: No / Yes. Recent trauma: No / Yes. Fever/infection signs: No / Yes.
SUBJECTIVE EXAMINATION:
Chief Complaint: ___.
Pain Assessment: Location: ___. Current intensity (NPRS 0-10): ___/10. Best in past 24 hours: ___/10. Worst in past 24 hours: ___/10. Quality: Sharp / Dull / Aching / Burning / Throbbing / Numbness / Tingling. Frequency: Constant / Intermittent. Duration of symptoms: ___.
Symptom Behavior: Aggravating factors: ___. Easing factors: ___. 24-hour pattern: Better in AM / Better in PM / No pattern. Night symptoms: None / Present – describe: ___.
Functional Limitations: Activities affected: ___. Work status: Working full duty / Modified duty / Off work. Recreational activities affected: ___.
Previous Treatment: Prior PT: No / Yes – describe: ___. Other treatments tried: ___. Effectiveness: ___.
Patient Goals: 1. ___ 2. ___ 3. ___
OBJECTIVE EXAMINATION:
Observation: Posture: ___. Gait: Normal / Antalgic / Ataxic / Other: ___. Assistive device: None / Cane / Walker / Crutches / Wheelchair. Skin/swelling: ___. Deformity: None / Present: ___.
Range of Motion:
| Joint/Movement | Active ROM | Passive ROM | End Feel | Pain |
|---|---|---|---|---|
| ___ | ___ | ___ | ___ | ___ |
| ___ | ___ | ___ | ___ | ___ |
| ___ | ___ | ___ | ___ | ___ |
| ___ | ___ | ___ | ___ | ___ |
Strength Testing (MMT 0-5):
| Muscle/Movement | Left | Right | Pain |
|---|---|---|---|
| ___ | ___ | ___ | ___ |
| ___ | ___ | ___ | ___ |
| ___ | ___ | ___ | ___ |
| ___ | ___ | ___ | ___ |
Neurological Screen: Sensation: Intact / Impaired: ___. Reflexes: Normal / Abnormal: ___. Myotomes: Intact / Weakness: ___. Dermatomes: Intact / Changes: ___.
Special Tests:
| Test Name | Left | Right | Interpretation |
|---|---|---|---|
| ___ | Pos / Neg | Pos / Neg | ___ |
| ___ | Pos / Neg | Pos / Neg | ___ |
| ___ | Pos / Neg | Pos / Neg | ___ |
Palpation: Tenderness: ___. Muscle tone: Normal / Increased / Decreased. Trigger points: None / Present: ___. Swelling/effusion: None / Present: ___. Temperature: Normal / Increased / Decreased.
Functional Assessment: Sit to stand: Independent / Modified independent / Supervision / Min assist / Mod assist / Max assist. Transfers: ___. Balance: Romberg: Pos / Neg. Single leg stance: L ___ sec / R ___ sec. Gait distance: ___.
Outcome Measures: [Select appropriate validated measures] NPRS: ___/10. Oswestry Disability Index: ___. DASH Score: ___. LEFS: ___. NDI: ___. Other: ___.
ASSESSMENT:
Clinical Impression: ___.
Problem List: 1. ___ 2. ___ 3. ___ 4. ___
Contributing Factors: ___.
Prognosis: Excellent / Good / Fair / Poor. Rationale: ___.
Rehab Potential: High / Moderate / Low.
PLAN:
Short-Term Goals (2-4 weeks): 1. ___ 2. ___ 3. ___
Long-Term Goals (6-12 weeks): 1. ___ 2. ___ 3. ___
Proposed Interventions: Manual therapy: ___. Therapeutic exercise: ___. Modalities: ___. Neuromuscular re-education: ___. Gait training: ___. Patient education: ___.
Frequency/Duration: ___ times per week for ___ weeks.
Home Exercise Program: Provided: Yes / No. Exercises: ___.
Patient Education: Topics covered: ___.
Plan for Reassessment: ___.
Therapist Signature: ___ Date: ___ | Time spent: ___ minutes
Template 2: Musculoskeletal Assessment (Regional)
Use for: Focused assessments of specific body regions (shoulder, knee, spine, etc.)
MUSCULOSKELETAL REGIONAL ASSESSMENT
Patient: [Name] | DOB: [Date] | Date: [Date] | Therapist: [Name]
Region Assessed: Cervical Spine / Thoracic Spine / Lumbar Spine / Shoulder / Elbow / Wrist-Hand / Hip / Knee / Ankle-Foot
SUBJECTIVE: Chief Complaint: ___. Mechanism of injury: Traumatic / Insidious / Repetitive / Unknown. Date of onset: ___. Pain location (body chart): ___. Pain intensity: ___/10. Aggravating: ___. Easing: ___. Functional impact: ___.
OBJECTIVE – CERVICAL SPINE: Observation: Forward head posture / Lateral shift / WNL. AROM: Flexion ___ / Extension ___ / R Rotation ___ / L Rotation ___ / R Sidebend ___ / L Sidebend ___. PROM: As above with end feel. Strength: Deep neck flexors ___ / Extensors ___. Neurological: UE sensation intact / impaired. UE reflexes: Biceps L/R ___ / Triceps L/R ___ / Brachioradialis L/R ___. Special tests: Spurling’s L/R ___ / Upper limb tension test ___ / Vertebral artery test ___. Palpation: ___.
OBJECTIVE – LUMBAR SPINE: Observation: Lordosis increased/decreased/WNL / Lateral shift / Scoliosis. AROM: Flexion ___ / Extension ___ / R Sidebend ___ / L Sidebend ___. Repeated movements: Flexion response ___ / Extension response ___. Neurological: LE sensation intact / impaired. LE reflexes: Patellar L/R ___ / Achilles L/R ___. SLR: L ___ degrees / R ___ degrees. Special tests: Prone instability ___ / FABER ___ / SI provocation ___. Palpation: ___.
OBJECTIVE – SHOULDER: Observation: Atrophy / Asymmetry / Scapular position. AROM: Flexion ___ / Abduction ___ / ER ___ / IR ___ / Hand behind back ___. PROM: As above. Strength: Flexion ___ / Abduction ___ / ER ___ / IR ___. Special tests: Neer’s ___ / Hawkins-Kennedy ___ / Empty can ___ / Lift-off ___ / Speed’s ___ / O’Brien’s ___ / Apprehension ___ / Load and shift ___. Palpation: AC joint / Biceps tendon / Rotator cuff insertion / Subacromial space.
OBJECTIVE – KNEE: Observation: Effusion / Alignment (varus/valgus) / Atrophy. AROM: Flexion ___ / Extension ___. PROM: As above with end feel. Strength: Quads ___ / Hamstrings ___. Special tests: Lachman’s ___ / Anterior drawer ___ / Posterior drawer ___ / Valgus stress ___ / Varus stress ___ / McMurray’s ___ / Thessaly ___ / Patellar grind ___. Palpation: Joint line / Patellar tendon / Quad tendon / ITB.
ASSESSMENT: Clinical diagnosis: ___. Stage: Acute / Subacute / Chronic. Irritability: High / Moderate / Low. Severity: Mild / Moderate / Severe.
PLAN: Treatment approach: ___. Precautions: ___. Goals: ___. Follow-up: ___.
Therapist Signature: ___ Date: ___
Template 3: Progress Note (SOAP Format)
Use for: Ongoing treatment sessions, follow-up visits
PHYSIOTHERAPY PROGRESS NOTE
Patient: [Name] | DOB: [Date] | Date of Service: [Date] | Visit Number: ___ of ___
Therapist: [Name] | Treatment Time: ___ minutes | CPT Codes: ___
SUBJECTIVE: Patient reports: ___. Pain level today: ___/10 (previous: ___/10). Change since last visit: Better / Same / Worse. Functional changes: ___. Compliance with HEP: Excellent / Good / Fair / Poor. New complaints: None / ___. Sleep: Improved / Same / Worse. Medications: No change / Changes: ___.
OBJECTIVE:
Key measures reassessed: ROM: ___. Strength: ___. Special tests: ___. Functional test: ___.
Treatment provided today:
Manual therapy (97140): ___ minutes. Techniques: Joint mobilization Grade ___ to ___ / Soft tissue mobilization to ___ / Manual stretching to ___.
Therapeutic exercise (97110): ___ minutes. Exercises performed: ___.
Neuromuscular re-education (97112): ___ minutes. Activities: ___.
Therapeutic activities (97530): ___ minutes. Activities: ___.
Gait training (97116): ___ minutes. Focus: ___.
Modalities: Hot pack / Cold pack / E-stim / Ultrasound / Other: ___. Duration: ___ minutes. Location: ___.
Patient response to treatment: Tolerated well / Fair tolerance / Poor tolerance. Post-treatment pain: ___/10. Immediate changes noted: ___.
ASSESSMENT: Patient is making: Excellent / Good / Fair / Slow / No progress toward goals. Goal status: STG 1: Met / Progressing / Not met. STG 2: Met / Progressing / Not met. STG 3: Met / Progressing / Not met. Barriers to progress: None / ___. Skilled PT continues to be necessary for: ___.
PLAN: Continue current POC / Modify POC: ___. HEP: Reviewed / Progressed / Modified: ___. Patient education: ___. Next visit: ___. Anticipated discharge: ___.
Therapist Signature: ___ Date: ___
Template 4: Neurological Physiotherapy Assessment
Use for: Stroke, TBI, spinal cord injury, Parkinson’s, MS, other neurological conditions
NEUROLOGICAL PHYSIOTHERAPY ASSESSMENT
Patient: [Name] | DOB: [Date] | Date: [Date] | Therapist: [Name]
Diagnosis: ___. Date of onset/injury: ___. Lesion level/location: ___.
MEDICAL HISTORY: Primary diagnosis: ___. Secondary diagnoses: ___. Precautions: Seizures / Orthostatic hypotension / Autonomic dysreflexia / DVT risk / Skin integrity / Cognitive impairment / Swallowing difficulties / Other: ___. Current medications: ___.
SUBJECTIVE: Patient/caregiver report: ___. Prior level of function: ___. Current living situation: ___. Support system: ___. Goals: ___.
OBJECTIVE:
Cognition/Communication: Alert and oriented x ___. Follows commands: 1-step / 2-step / 3-step. Communication: Intact / Impaired: ___. Attention: Intact / Impaired. Memory: Intact / Impaired. Safety awareness: Intact / Impaired.
Tone Assessment: Modified Ashworth Scale:
| Muscle Group | Left | Right |
|---|---|---|
| UE Flexors | ___ | ___ |
| UE Extensors | ___ | ___ |
| LE Flexors | ___ | ___ |
| LE Extensors | ___ | ___ |
Motor Function: Voluntary movement: Present / Absent. Synergy patterns: Flexion synergy / Extension synergy / Isolated movement. Coordination: Finger-nose ___ / Heel-shin ___ / Rapid alternating ___.
Sensation: Light touch: Intact / Impaired / Absent – distribution: ___. Proprioception: Intact / Impaired / Absent. Temperature: Intact / Impaired. Pain: Intact / Impaired.
Reflexes: DTRs: Biceps L/R ___ / Triceps L/R ___ / Patellar L/R ___ / Achilles L/R ___. Pathological reflexes: Babinski L/R ___ / Clonus L/R ___.
Balance: Sitting static: Independent / Supervision / Support needed. Sitting dynamic: ___. Standing static: ___. Standing dynamic: ___. Berg Balance Scale: ___/56. Timed Up and Go: ___ seconds.
Mobility: Bed mobility: Rolling L/R ___ / Supine to sit ___ / Scooting ___. Transfers: Sit to stand ___ / Stand pivot ___ / Squat pivot ___. Gait: Ambulates ___ feet with ___ assist and ___. Gait deviations: ___. Stairs: ___ steps with ___ and ___. Wheelchair mobility: ___.
Functional Scales: FIM Score: ___. NIHSS: ___. Fugl-Meyer: UE ___/66 LE ___/34. 10-Meter Walk Test: ___ seconds. 6-Minute Walk Test: ___ meters.
ASSESSMENT: Patient presents with ___ following ___. Primary impairments: ___. Functional limitations: ___. Rehab potential: High / Moderate / Low. Prognosis: ___.
PLAN: STGs: ___. LTGs: ___. Interventions: Task-specific training / Neurodevelopmental techniques / Strengthening / Balance training / Gait training / Transfer training / Wheelchair training / Constraint-induced therapy / Other: ___. Frequency: ___. Duration: ___. Discharge disposition: Home / SNF / IRF / LTAC / Other: ___.
Therapist Signature: ___ Date: ___
Template 5: Discharge Summary
Use for: End of care, discharge planning, transition of care
PHYSIOTHERAPY DISCHARGE SUMMARY
Patient: [Name] | DOB: [Date] | Discharge Date: [Date] | Therapist: [Name]
Date of Initial Evaluation: ___ | Total Visits: ___ | Total Duration of Care: ___
DIAGNOSIS/REASON FOR REFERRAL: ___.
INITIAL PRESENTATION: Chief complaint: ___. Key impairments at eval: ___. Functional status at eval: ___. Initial pain: ___/10. Initial outcome measures: ___.
TREATMENT PROVIDED: Interventions utilized: Manual therapy / Therapeutic exercise / Neuromuscular re-education / Gait training / Balance training / Modalities / Patient education / Other: ___. Summary of treatment progression: ___.
PROGRESS AND OUTCOMES:
| Measure | Initial | Discharge | Change |
|---|---|---|---|
| Pain (NPRS) | ___/10 | ___/10 | ___ |
| ROM: ___ | ___ | ___ | ___ |
| Strength: ___ | ___ | ___ | ___ |
| Outcome measure: ___ | ___ | ___ | ___ |
| Functional: ___ | ___ | ___ | ___ |
GOAL ACHIEVEMENT: STG 1: Met / Partially met / Not met. STG 2: Met / Partially met / Not met. LTG 1: Met / Partially met / Not met. LTG 2: Met / Partially met / Not met.
REASON FOR DISCHARGE: Goals met / Plateau reached / Patient request / Non-compliance / Medical status change / Insurance / Relocation / Other: ___.
DISCHARGE STATUS: Current pain: ___/10. Current functional status: ___. Activity level: ___. Work status: ___. Return to sport status: ___.
DISCHARGE RECOMMENDATIONS: Home exercise program: Provided and reviewed. Continued exercises: ___. Activity modifications: ___. Precautions: ___. Follow-up with physician: ___. Return to PT if: ___.
EQUIPMENT/DME: At discharge patient using: ___. Equipment recommended: ___.
PATIENT EDUCATION: Topics reviewed: ___. Patient verbalized understanding: Yes / No.
Therapist Signature: ___ Date: ___
Documentation Best Practices
Medical Necessity Requirements
Ensure documentation supports the skilled nature of physiotherapy services: document why skilled intervention is required rather than independent exercise, demonstrate clinical reasoning and decision-making, show measurable progress toward functional goals, explain modifications made based on patient response, and identify specific impairments requiring skilled treatment.
Goal Writing (SMART Format)
Effective goals should be Specific, Measurable, Achievable, Relevant, and Time-bound. Example: “Patient will ascend/descend 12 stairs with one handrail and no assistive device in 30 seconds to return to work in 2-story building within 4 weeks.”
Common Documentation Errors
Avoid vague subjective reports like “patient doing better” without specifics. Do not use incomplete objective measures missing baseline comparisons. Ensure goals are not too vague or immeasurable. Document treatment rationale for all interventions. Include patient response and tolerance. Document skilled services clearly to support medical necessity.
AI-Powered Physiotherapy Documentation
While templates ensure consistency, AI documentation tools can transform your assessment workflow by capturing clinical findings automatically during patient interactions.
How AI Documentation Works for Physio
AI ambient documentation listens to your patient assessment conversation, extracts relevant clinical information including subjective reports, objective findings you verbalize, and treatment discussions, structures the content into proper SOAP format, suggests appropriate billing codes based on services documented, and presents the note for your review and signature.
Benefits for Physiotherapists
| Factor | Manual Documentation | AI Documentation |
|---|---|---|
| Time per evaluation | 15-30 minutes | 2-5 minutes review |
| Time per progress note | 5-10 minutes | 1-2 minutes review |
| End-of-day documentation | 30-60 minutes | Minimal |
| Completeness | Variable | Consistent capture |
| Patient interaction | Interrupted by typing | Full engagement |
Learn more about voice recognition in healthcare and healthcare automation.
Frequently Asked Questions
What outcome measures should I use?
Select validated, condition-specific measures. Common choices include NPRS for pain, Oswestry or NDI for spine, DASH or QuickDASH for upper extremity, LEFS for lower extremity, Berg Balance Scale for balance, and TUG or 6MWT for functional mobility. Use measures with established MDC (minimal detectable change) and MCID (minimal clinically important difference) values.
How detailed should my objective examination be?
Document all findings relevant to your clinical hypothesis and treatment plan. Initial evaluations should be comprehensive. Progress notes should focus on key measures being tracked and any new findings. Always document enough to justify your assessment and treatment approach.
How do I document when a patient is not progressing?
Document objectively: current status compared to baseline, barriers identified (compliance, complexity, comorbidities), modifications attempted, clinical reasoning for continued or modified treatment, and discussion with patient about options including discharge if plateau confirmed.
What should I include in home exercise programs?
Document exercises prescribed with sets, reps, and frequency. Note that instructions were provided and patient demonstrated understanding. Include any modifications or progressions discussed. Document patient compliance at subsequent visits.
How long should I keep physiotherapy records?
Retention requirements vary by jurisdiction but typically range from 7-10 years after the last date of service, or longer for minors (until age of majority plus retention period). Check your state/province licensing board and facility policies for specific requirements.
Automate Your Physiotherapy Documentation
Templates provide structure, but AI documentation provides freedom—freedom to focus fully on your patient while comprehensive notes generate automatically.
NoteV’s AI documentation captures your assessment conversations and treatment sessions, producing detailed SOAP notes without interrupting patient care. No more staying late to finish documentation.
Physiotherapists using NoteV report:
- 70 percent reduction in documentation time
- More thorough clinical notes
- Better patient engagement during sessions
- Improved billing code capture
- Reduced documentation-related burnout
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Disclaimer: These templates are provided for educational purposes and should be adapted to meet your specific practice requirements, regulatory standards, and facility policies. Documentation requirements vary by jurisdiction, payer, and practice setting. Consult with your licensing board and compliance officer regarding documentation requirements in your area.
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