Musculoskeletal Physical Exam Findings Record Form
Record patient details, symptoms, objective musculoskeletal exam findings, and the clinician’s assessment and plan.
Patient and Exam Context
Patient Name or Chart ID
*
Date of Exam
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Examiner Name and Role
*
Reason for Visit / Chief Complaint
*
Affected Side / Body Region(s) Examined
*
Neck
Shoulder
Elbow
Wrist/Hand
Back
Hip
Knee
Ankle/Foot
Multiple Regions
Bilateral
Other
Onset / Duration of Current Issue
Subjective Musculoskeletal Symptoms
Pain location
*
Pain severity
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
Pain quality
*
Aching
Sharp
Burning
Stiffness
Throbbing
Other
Aggravating factors
Movement
Rest
Standing
Walking
Lifting
Reaching
Exercise
Stairs
Other
Relieving factors
Rest
Ice
Heat
Medication
Stretching
Massage
Elevation
Other
Associated symptoms present
Swelling
Stiffness
Weakness
Numbness
Tingling
None
Functional limitation description
Physical Examination Findings
Inspection abnormalities
Swelling
Redness
Bruising
Deformity
Asymmetry
Muscle atrophy
None
Palpation findings
Tenderness
Crepitus
Warmth
Edema
Bony tenderness
Soft tissue tenderness
None
Range of motion
Strength grading
Gait observation
Please Select
Normal
Antalgic
Unsteady
Limping
Assisted
Not assessed
Other
Posture / stance notes
Neurovascular status
Please Select
Normal
Abnormal
Not assessed
Neurovascular notes
Special orthopedic tests
Assessment and Plan
Overall Assessment / Impression
*
Suspected Diagnosis / Working Diagnosis
*
Severity / Functional Impact
*
Mild
Moderate
Severe
Treatment Provided Today
Education
Rest
Ice/Heat
Medication Review
Exercises
Brace/Splint
Referral
Imaging Ordered
Follow-up Planned
Other
Activity Restrictions / Precautions
Follow-up Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional Comments
Save Findings
Should be Empty: