Physiotherapy assessment and progress report
Two documents in one file: the initial assessment you write at the first session, and the progress report you send back to the referring doctor. The report repeats the assessment’s measures, so the change is plain to see.
Download
- Word · English.docx · 70 KB
- PDF · English.pdf · 324 KB
- Word · Arabic.docx · 70 KB
- PDF · Arabic.pdf · 146 KB
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What is in the file
| Assessment, page 1 | Referral source and diagnosis, history, red flags screened, and a pain section: front and back body diagram, a 0–10 scale and the questions that describe the pain. |
|---|---|
| Assessment, page 2 | Range of motion table (joint, movement, side, active, passive, normal), strength grades, functional tests, short and long-term goals with how each is measured, the plan and the patient’s consent to treat. |
| Progress report | Dates covered, sessions attended of those planned, pain then and now, range of motion then and now in one table, functional change, goals met, the decision (continue, modify or discharge) and a recommendation to the referring doctor. |
How to use it
Add your letterhead
Open the Word file and put your logo and clinic details in the header box.
Assess at the first session
Fill in pages 1 and 2. Write goals you can measure, such as a range or a walking distance.
Measure the same way later
At re-assessment, take the same measurements so the then-and-now columns compare like with like.
Send the report
Fill in page 3 and send it to the referring doctor with your recommendation.
Who it is for
Physiotherapy and rehabilitation clinics, sports injury clinics and orthopaedic practices with a physiotherapist on staff. The Arabic file runs right to left and puts the front of the body on the right; the English file is the same form in English.
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Questions
Why is the progress report in the same file?
Because it reuses the assessment’s measures. Keeping them together means the numbers you compare are the ones you actually recorded.
Can I add my own outcome measures?
Yes. The Word file is fully editable: add a row to the functional tests table for the scale your clinic uses.
Does it include the patient’s consent?
Yes, a short consent to treat with signature lines for the patient or guardian and the physiotherapist. Have your own wording reviewed if your facility requires it.
How do I write the report itself?
Our guide on writing a physiotherapy report covers what referring doctors look for and how to phrase the recommendation.
Every session measured, every report ready
In Medicolize the assessment sits on the patient’s chart, sessions are tracked against the plan, and the progress report pulls the first and latest measures for you. Thirty minutes on your own clinic.