This is your standing chart with our clinic — one copy that you and your therapist keep current across every episode of care. It is not a per-visit note. Update it whenever something changes: new medication, new surgery, a new referral, a change of insurance.
Patient Identity & Contact
Occupation / main daily physical demands:
Referring Physician & Care Team
Referring physician / surgeon:
General practitioner (if different):
Other clinicians involved (orthopaedic, rheumatology, pain clinic, chiropractic, personal trainer):
Insurance & Payer Details
Visits authorised / used this year:
Secondary payer, workers-compensation or auto claim details:
Permanent Medical History
Surgeries and dates, fractures, significant injuries — anything permanent that shapes how we treat you.
Imaging on file (X-ray, MRI, CT, ultrasound) — type, region, date and findings:
Comorbidities that affect exercise tolerance (diabetes, cardiac disease, asthma, arthritis, neurological conditions):
Current Medications & Allergies
Medications, dose and what each is for (include blood thinners and steroids):
Allergies and sensitivities (latex, adhesive tape, topical gels, medication):
Medications last reviewed:
Standing Precautions & Red Flags
Every therapist who treats you reads this section first. Tick everything that applies and keep it current.
Detail of the precautions ticked above, and who set them:
One row per episode of care — from first evaluation to discharge. Add a row each time you come back to us.
Cumulative scores across all episodes — Oswestry, DASH, LEFS, numeric pain rating, timed-up-and-go, single-leg hop. Keeping them in one table makes the long-term trend visible at a glance.
Upload imaging reports, referral letters, operative notes, insurance authorisations and any specialist correspondence.
Scheduling & Communication Preferences
Preferred days and times:
Preferred therapist (if any):
Dated entries as things change — a new flare, a change in work duties, a return to sport, a decision agreed with the referring physician. Newest at the top.
Keep this record current — it is the chart every therapist in the clinic works from.