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Keep the patient’s request and goals in their own words.
Practical guide · Physiotherapy case history
Physiotherapy case history: gather information without losing the thread
Prepare the interview, keep track of how the complaint developed and highlight the patient’s goals. Manu organises the notes you gather to make documenting the patient record easier.
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Before you start
- Review the history and relevant documents.
- Check the patient’s feedback.
- Prepare the points to clarify during the interview.
Updated on 21 October 2026 · Written by the Manu team
A clear basis for clinical reasoning and documentation
Your expertise and the person’s priorities continue to guide information gathering.
Clarify
Distinguish known information from points to check during the session.
Connect
Carry information from the interview through to the clinical report and follow-up.
A framework for the interview
This checklist helps organise information; it does not replace your clinical assessment.
Understand the situation
- Main reason for the visit, location and discomfort experienced.
- Onset, progression and previous episodes.
- Activities that aggravate or relieve symptoms.
- Impact on daily life, work and sport.
Understand the person
- History and context relevant to the assessment.
- The patient’s goals and expectations.
- Constraints relating to time, equipment or organisation.
- Points still to clarify and concerns to assess.
An example of structured information gathering
Fictional example: retain the facts, then address the questions still open.
Information gathered
Low back pain beginning after a house move. Partial improvement, with greater discomfort in the morning. Prolonged bending and lifting are difficult.
Stated goal
Return to work without persistent pain. Work activities and return-to-work constraints still need to be clarified.
What remains to be done
The physiotherapist continues the interview and examination, prioritises the information, then decides what to include in the summary.
From interview to patient record
A simple transition from gathering information to preparing the clinical report.
Prepare
Open the patient record from the calendar and review the history, progress assessment and available feedback.
Collect
Enter your notes or, in practice, use a recording after informing the patient and obtaining their consent.
Structure and review
Check the chronology, wording and any information still missing.
Document
Choose an assessment or clinical report template and add the observations actually gathered.
Explore further
Choose the next useful step for your practice.
Questions about practice and use
Practical answers to help you document care and prepare follow-up.
What information should I gather during a physiotherapy case history?
Clarify the reason for the visit, the history of the problem, its impact, relevant history and treatments, activities and expectations. The interview captures the patient’s perspective; the examination adds further information to the record. Choose questions relevant to the situation.
A template makes information easier to find, but an uncompleted section must not be treated as a negative answer.
How can I make the patient’s goal clear?
Ask what the person wants to regain or improve in daily life, then explore their priorities, constraints and available resources. Rephrase the goal together to check that you mean the same thing.
Fictional example: “I would like to be able to walk to work again.” This expectation provides a concrete topic to clarify together; it does not, by itself, determine a programme or a timeframe.
How should I document uncertain or missing information?
Separate what the patient reports, what you observed and what remains to be clarified. A note such as “onset date to be confirmed” is more accurate than an assumed date. Review important information with the patient or using the available documents.
These distinctions remain useful when the notes are later used to prepare a clinical report.
Does Manu conduct the interview for me?
No. The physiotherapist conducts the interview and examination. Manu helps organise the information gathered and prepare a document for review.
Do I need to complete every section?
The template is a guide. You choose questions that suit the context and distinguish what has been gathered from what remains to be clarified.
How do I move from the case history to the clinical report?
Review the information, choose the appropriate document template and add the actual findings from the session before approval.
Reference documents: ANAES / HAS — The patient record in physiotherapy (March 2000) · HAS — Elements for developing a shared decision-making aid for patients and healthcare professionals (April 2018). Sources consulted on 21 October 2026. The writing examples provided here are fictional.