VPJ Physiotherapy Assessment Form
Full Name
*
First Name
Last Name
Occupation
*
What is your age?
*
Gender
*
Male
Female
Other
Contact Number
*
Format: (000) 000-0000.
Email Address
example@example.com
Language
*
English
Kannada
Telugu
Tamil
Others
Married
Yes
No
Pregnant
*
Yes
No
NA
Other
Concerned about
*
Neck
Low Back
Knee
Shoulder
Ankle
Upper back
Calf
Heel
Wlbow
Wrist
Foot
Hip
Other
This issue is
1st time
2-3times
Chronic
This issue started due to
Trauma
Strain
Exercise
Suddenly
Gradually
others
Your sleep pattern
Good
Poor
Disturbed due to pain
Check the conditions that apply to you or any member of your immediate relatives:
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Stroke
Other
The disease/ disorder that you' re currently experiencing:
*
Chest pain
Respiratory
Cardiac disease
Hematological
Lymphatic
Neurological
Psychiatric
Gastrointestinal
Genitourinary
Weight gain
Weight loss
Musculoskeletal
Diabetic
Blood pressure
Thyroid
Other
Are you currently taking any medication?
Yes
No
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of
Giddiness
Yes
Not now
Rarely
Not at all
Any investigation, x-ray,MRI report
Yes
No
Others
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of
Underwent any surgeries
Yes
No
Planing shortly
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of
History of fall / trauma /fracture
Few days back
Few weeks back
Year back
Long back
Not applicable
Other
Pain scale ( how much pain do you feel )
*
0 - No pain at all
1-3- Mild pain
4-6 – Moderate to Severe Pain
7-9 – Very severe pain
10 - Unbearable pain
Side of pain
*
Right
Left
Middle
Site of pain
*
Pain since
Few days
Few months
Few years
Few hours
Swelling
Yes
No
Sometime back
Movements
Full range and painfree
Full range but painfull
Restricted and painful
Restricted and painfree
Pain during
*
Sitting
Standing
Walking
Stair climbing
Descending stairs
Lying stright
Lying on stomach
Lying right
Lying left
Driving
Lifting weights
Bending down
Sit to stand
Turning
Other
Which position makes you better
*
Sitting
Lying stright
Lying right
Lying left
Lying on stomach
Standing
Walking
None
Other
Muscle power
*
Feeling fully strong
Feeling partially weak
Fully weak
Normal
Balance
Sitting good
Standing good
Upper limb good
Lower limb good
Sitting bad
Standing bad
Upper limb bad
lower limb bad
All normal
Underwent physiotherapy
*
Yes
No
Other therapy
Anything related to your issue , you need to share.
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