Physiotherapy Initial Assessment Questionnaire Form
Please complete this initial assessment to help us understand your current condition and needs before your physiotherapy session.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
What is the main reason for your visit?
*
Where are you currently experiencing symptoms?
*
Neck
Shoulder
Back
Knee
Ankle/Foot
Other
Please rate your current pain level
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst possible pain
10
0 is No pain, 10 is Worst possible pain
How much do your symptoms affect your daily activities?
*
Not at all
0
1
2
3
4
5
6
7
8
9
Extremely
10
0 is Not at all, 10 is Extremely
Please indicate any previous injuries or relevant medical history
Functional Ability Assessment
*
Rows
No difficulty
Mild difficulty
Moderate difficulty
Severe difficulty
Unable
Walking
1
2
3
4
5
Climbing stairs
6
7
8
9
10
Lifting/carrying objects
11
12
13
14
15
Self-care (dressing, bathing)
16
17
18
19
20
Submit Assessment
Should be Empty: