This 6-page document contains a musculoskeletal physical therapy assessment form. It collects information about a patient's chief complaint, medical history, physical examination findings, range of motion measurements, functional abilities, and proposed physiotherapy treatment plan. The form gathers details on pain characteristics, aggravating/relieving factors, and effects on daily activities. It also documents vital signs, posture, gait, joint mobility, muscle strength, and special tests. The physiotherapy management section outlines short-term and long-term goals and a treatment plan.

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THE SARVAJANIK COLLEGE OF PHYSIOTHERAPY, SURAT
Hajee A.M. Lockhat & Dr. A.M. Mulla Sarvajanik Hospital, Surat
MUSCULOSKELETAL PHYSICAL THERAPY ASSESSMENT
Name: _______________________________________________ Date: ________________
Age/Sex: __________ Occupation: _____________________ OPD No.: ____________
Address: _____________________________________________ Ref Dept.: ____________
_____________________________________________________ Handedness: __________
Contact No.: __________________________________________________________________
Height (cm): _________ Weight (kg): _______________ BMI (kg/m2): ________
Medical Diagnosis (if any): ______________________________________________________
Special Precautions (if any): ____________________________________________________
Chief Complaint:
Present H/O:
Pain H/O:
Intensity (NRS): ----------------------------------------------------------------------
(No pain) 0 1 2 3 4 5 6 7 8 9 10 (Maximum)

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Onset:
Duration:
Quality: Prick / Dull ache / Burning / Throbbing / Pulling / Sharp shooting
Rhythm: Constant / Intermittent
Manner Of Expressing Pain: Verbal / Facial expression
Aggravating Factors:
Releiving Factors:
Effects Of Pain On Physical Activity:
Getting in/out of bed, Getting in/out of chair, Standing/Walking, Walking up/down stairs,
Work activities, Other activities (sitting, cooking, dressing, cleaning, lifting, etc.)
Accompanying symptoms: Sleep:
Appetite: Irritability:
Medical / Surgical / Occupational H/O :
Personal History:
a. Smoking: Yes / No Since:_____________
b. Tobacco chewing: Yes / No Since:_____________
c. Alcohol consumption: Yes / No Since:_____________
d. Physical / Recreational activity:

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Family History:
Socio-economic Status: Poor / Fair / Good
Investigation:
Vital Signs:
Heart Rate: /min Respiratory Rate: /min
Blood Pressure: / mmHg Temperature:
.
C
General Examination:
General Body Built:
Posture:
Gait:
Local Examination:
Temperature:
Swelling: ______________________________ Soft / Firm / Hard Pitting / Nonpitting
Tenderness:
Spasm:
Crepitus:
Attitude of the limbs / body part:
Any other findings:(e.g.,Trophical changes / Scar / Wound):

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Range Of Motion:
Right Left
Date Joint-- Date
Active Passive Active Passive Active Passive Active Passive
Flexion
Extension
Abduction
Adduction
IR / Supination /
Inversion
ER / Pronation /
Eversion
Other Joint:
Tightness / Contracture / Deformity:
Girth Measurement:
Muscle Power:
Limb Length Measurement:
Functional Evaluation:
Upper Limb:
Dressing:
Combing:
Washing:
Eating:
Perineal and back hygiene:
Other:
Lower Limb:
Walking:
Stair Climbing:
Squatting:
Crossed Leg Sitting:
Cycling:
Other:
Gait Analysis:
FIM :-
1 – Total Assistance
Patient- <25%, Assistant- > 75%
2 – Max. Assistance
Patient- 25%, Assistant- 75%
3 – Moderate Assistance
Patient- 50%, Assistant- 50%
4 – Minimal Assistance
Patient- 75%, Assistant- 25%
5 – Supervision
Cues without physical contact
6 – Modified Independence
Assistive devices, takes more time
7 – Completely Independent

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Special Tests:
Other System Examination:
 Cardiovascular / Pulmonary System:
 Neuromuscular System:
 Any Other System:
PROBLEM LIST:
PFD (Physical & Functional Diagnosis):
PHYSIOTHERAPY MANAGEMENT
AIMS:
-Short Term:
-Long Term:
TREATMENT PLAN:

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HOME PROGRAM:
ERGONOMIC ADVICES:
Prognosis:
Physical Therapist’s Sign