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General Physiotherapy Assessment

(Quick Assessment Tool)
Name: CHI:
ACTION SYSTEM CHECK ACHIEVED Further Investigations required
Yes No /comments
Get client to stand Lordosis, Kyphosis,
straight Swayback etc
Head movement in Neck
all planes
Reach to the ceiling Shoulder (Sh)
(sky) Flexion
Touch back of head Sh Abd & Int Rot
Elbow Flex, Ext
Touch lower back Sh Add & Ext Rot
Elbow Flex & Ext
Palm ↕ Sup and Pronation

Wrist ↕ ↔ Flex, Ext, Med & Lat

deviation
Make a fist Flex & Add (Fingers)

Open fist (right out) Ext & Abd (Fingers)

Standing on one Hip / Knee Flex & Ext

leg balance
Standing (from waist) Lumbar movements
Touch toes, side stretch
& twist round
Push up on tip toes Plantar / Dorsiflexion

Sit → Stand (with & Knee Flex, Ext &

without hands) Power
Proprioception Balance, Fine motor
stand still, finger → control
Nose (Eyes closed)
Shoes off (in sitting) Hip Flex, Abd &Ext
Rot
Sitting, foot ↔ Inversion / Eversion

Sitting, toe curl Flex & Add

(tight)
Sitting, toes open Ext & Abd
(fully)
Gait (Circle) Waddling , Scissoring , Shuffling , Stepping , Toe walking , Spastic gait (Comment)

Completed by: ………………………… Signature: ………………………………….

Designation: ………………………… Date: ………………………………….
ACPPLD Scotland, Version 2 2010
 Page 2/2

General Physiotherapy Assessment

(Quick Assessment Tool)
Name: CHI:

Functional Questions? Yes No Comments

Do you have a bath or a shower at home? Do
you manage independently?
Can you wash and dress independently?
Can you brush or wash your own hair?
Can you put your shoes on independently?
Do you have stairs at home (how many)
Can you manage stairs without hand rails?
Is there any ADL that you don’t like?
Do you have any problems with eating and
drinking? (i.e. cups, cutlery)
How far can you walk?
Have you had any falls recently?
Do you ever feel pain (where)?

What exercise do you do regularly?

General Impression / Problems

Goals/ Advice given

Completed by: ……………………… Signature: ………………………

Designation: ………………………… Date: ……………………………

ACPPLD Scotland, Version 2 2010