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Physio intake and body map

Example template only. Not legal or clinical advice. Review and adapt before use. Not endorsed by any government agency. Last reviewed 14 October 2026.

Rules differ by state; check yours.

Physio and similar Australian clinics taking a first history.

The person marks where it hurts, scores pain from 0 to 10, and says what they want to get back to. The body map is the same one used on the allied health demo. Consent to assessment is a separate tick.

Physio and allied health at nopen

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Demo only, no real details

Physio intake and body map

Example template only. Not legal or clinical advice. Review and adapt before use. Not endorsed by any government agency. Last reviewed 14 October 2026.

DD/MM/YYYY

Where it hurts

Left and right are the person's own.

Tap a region, or choose from the list.

Choose areas from a list
Front
Back

DD/MM/YYYY

Fields

  • Name and date of birth

    So the note matches the person.

  • Body map

    Front and back. They tap the areas that hurt.

  • Pain now

    0 is no pain. 10 is the worst.

  • What happened

    A short account and the date it started.

  • Goal

    What they want to get back to.

  • Consent

    Assessment, and use of the answers for care.

Questions

Is the body map the demo one?

Yes. The same front and back map, in a blank nopen form.

Does this include a Medicare plan question?

Not in this blank. Ask for it under minor changes if your clinic needs it. It would be a label only.

About these templates

These templates are examples only, to help you get started. They are general information, not legal, medical, clinical or professional advice, and they may not suit your business, your profession or your state or territory.

Before you use any template, you must review and adapt it, and have it checked where needed, so it fits your services, your professional body's rules, privacy and health records laws, and the law where you operate. This matters most for consent, waiver, privacy and minors' forms. You are responsible for the forms you use and the information you collect.

To the extent the law allows, Nopen gives no warranty that the templates are complete, current or fit for any purpose, and is not liable for loss arising from their use. Nothing here excludes, restricts or modifies any right or remedy you have under the Australian Consumer Law that cannot lawfully be excluded.

The templates are not endorsed by or connected with any government agency, including Services Australia, Medicare or the NDIA. Do not add government logos, the Commonwealth Coat of Arms or other official marks to them. Fields that refer to government numbers (such as a Medicare card number) are labels only.

Templates were last reviewed on 14 October 2026. Laws change, so check that a template is current before you rely on it.

Example template only. Not legal or clinical advice. Review and adapt before use. Not endorsed by any government agency. Last reviewed 14 October 2026.

Drafted 14 October 2026.