A physiotherapy assessment form is used by physiotherapists to determine if a patient needs treatment and to understand their current health status. The form collects information such as the patient's name, age, medical history, current medications, bone or joint issues, prior surgeries, risk of falling, and history of previous physiotherapy.

1. 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?