Title Page

  • Patient Name

  • Assigned Physical Therapist

  • Conducted on

  • Location

Subjective Data

  • Age

  • Race

  • Gender

  • Chief complaint

  • History of Present Illness (location, quality, severity, timing, setting, alleviating/ aggravating factors, associated signs and symptoms)

  • Past Medical History (allergies, current medication, injuries, hospitalizations, surgeries)

  • Family History

  • Social History

  • Review of Systems

Objective Data

  • Height (in)

  • Weight (lbs)

  • BMI

  • Temperature

  • Blood Pressure (BP)

  • General Appearance

  • Laboratory Results


  • General Observations


  • Treatment Plan


  • Additional Notes

  • General Observations

  • Name & Signature of Attending Medical Practitioner

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.