Physiotherapy Daily Activity Report Form
Document daily physiotherapy sessions, track activities, pain status, and follow-up needs.
Patient/Client Name
*
First Name
Last Name
Session Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Activities Completed
*
Range of Motion Exercises
Strengthening Exercises
Balance Training
Gait Training
Manual Therapy
Education/Advice
Other
Exercise Adherence
*
Full adherence
Partial adherence
No adherence
Pain Status (Current Session)
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
Functional Changes Observed
Therapist Notes
Follow-up Needs
Continue current plan
Modify exercises
Refer to specialist
Schedule next session
Other
Submit Report
Should be Empty: