Physiotherapy initial assessment report

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Worker Information

As shown on valid government-issued ID
As shown on valid government-issued ID
Part of body affected (check all that apply)
if no family doctor please state none.

Heath care provider information

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Subjective findings

Objective Findings

Test name Result
Critical job demand Current ability Job match

Treatment plan

Treatment goals Recommended treatment (Methodology)
# of visits/week Duration

Return to work

Signature, consent and declaration