Clinic template

A Cliniko treatment note template for a physio initial assessment

This template gives a physiotherapy initial assessment in 12 sections using Cliniko's six question types: history, body chart, red flag screen, objective tests, outcome measures, assessment, consent and plan. Build it under Settings > Treatment note templates, or import a colleague's exported .json file. Cliniko's help centre documents both.

Last checked 25 Sep 2026 against the sources listed at the end of this page.

Free template · Cliniko

Treatment note: initial assessment: physiotherapy

The template: 41 fields

Section	Field	Type	Notes
Presenting complaint	Reason for visit, in the patient's words	Paragraph	Cliniko type: Paragraph text.
Presenting complaint	Area(s) affected	Checkboxes	Options: Neck / Thoracic / Lumbar / Shoulder / Elbow / Wrist and hand / Hip / Knee / Ankle and foot / Other. Keeps notes searchable across patients.
Presenting complaint	Onset date	Text	Use Cliniko's Date question type here if you want a date picker.
Presenting complaint	Mechanism of onset	Radio	Cliniko type: Multiple choice. Options: Traumatic / Gradual / Insidious / Post surgical / Unknown.
Presenting complaint	Referral source	Radio	Options: Self / GP (Medicare CDM) / DVA / Workers compensation / CTP / Specialist / Other. Match the funding body so billing lines up.
Body chart	Symptom map	Body chart	Add a full body front and back chart, plus a regional chart if you use one. Mark pain, pins and needles, numbness and referral with a legend you use consistently.
Symptom behaviour	Pain now, best and worst (NPRS)	Text	Cliniko has no number type, so use Single line text, for example 4 / 2 / 7.
Symptom behaviour	Symptom quality	Checkboxes	Options: Ache / Sharp / Burning / Throbbing / Pins and needles / Numbness / Stiffness / Weakness.
Symptom behaviour	Aggravating factors	Paragraph	Include how long before symptoms come on and how long they take to settle (irritability).
Symptom behaviour	Easing factors	Paragraph
Symptom behaviour	24 hour pattern	Radio	Options: Worse in the morning / Worse through the day / Worse at night / No pattern. Add a stiffness duration if morning is ticked.
Symptom behaviour	Current trend	Radio	Options: Improving / Static / Worsening.
Red flag screen	Red flags screened	Checkboxes	Tick each one asked and cleared: Unexplained weight loss / Night pain unrelieved by rest / Fever or unwell / History of cancer / Saddle anaesthesia / Bladder or bowel change / Progressive neurological deficit / Significant trauma. Leave a default answer blank so nothing is ticked by accident.
Red flag screen	Red flag findings and action	Paragraph	Record any positive finding and the onward referral made.
Yellow flags and goals	Psychosocial factors	Paragraph	Beliefs about the pain, fear of movement, work and mood factors.
Yellow flags and goals	Patient goals	Paragraph	In the patient's words. These are what the plan and discharge are measured against.
History	Previous episodes and treatment	Paragraph
History	Past medical and surgical history	Paragraph	Pull from the patient's intake form if they completed one, and confirm verbally.
History	Medications	Paragraph	Include anticoagulants and steroids.
History	Imaging and investigations	Paragraph	Type, date and result. Attach reports to the patient file rather than retyping them.
History	Work, sport and activity	Paragraph
Objective	Observation and posture	Paragraph
Objective	Active range of movement	Paragraph	Default answer can carry a small grid, for example Flexion: / Extension: / Left rotation: / Right rotation:, so each note starts with the same prompts.
Objective	Passive and accessory movement	Paragraph
Objective	Strength	Paragraph	Grade, or dynamometer readings where used.
Objective	Neurological examination	Radio	Options: Not indicated / Normal / Abnormal (see notes). Follow with a Paragraph for dermatomes, myotomes and reflexes.
Objective	Neurological findings	Paragraph
Objective	Special tests	Paragraph	Test name and result, for example Lachman: negative.
Objective	Palpation	Paragraph
Objective	Functional tests	Paragraph	Squat, single leg stance, gait, sit to stand, as relevant.
Outcome measures	Measure used	Checkboxes	Options: PSFS / NPRS / Oswestry (ODI) / Neck Disability Index / QuickDASH / LEFS / Other. Pick the one that fits the region and repeat it at review.
Outcome measures	Baseline scores	Text	Score per measure. Needed for Medicare, DVA and insurer reports that ask for progress against baseline.
Assessment	Clinical impression	Paragraph	Working diagnosis and differentials.
Assessment	Contributing factors	Paragraph
Assessment	Prognosis	Paragraph	Expected timeframe and number of sessions, as explained to the patient.
Consent	Informed consent	Checkboxes	Options: Findings explained / Treatment options and material risks explained / Costs explained / Questions answered / Consent given for assessment and treatment. Record anything specific (dry needling, manipulation, internal examination) in the next field.
Consent	Consent notes	Paragraph	Specific techniques consented to, anything declined, and whether a separate signed form is on file.
Treatment today	Treatment provided	Paragraph	Techniques, dosage and the patient's response.
Plan	Home exercise programme	Paragraph	Exercises, sets and repetitions, or a note that a programme was sent.
Plan	Advice and education	Paragraph
Plan	Plan and review	Paragraph	Frequency, next review, when outcome measures will be repeated, and any referral or letter to the GP.

Build it in Cliniko

Build it by hand: log in as an Administrator, go to Settings > Treatment note templates, click Add template and name it Physio initial assessment.
Click Add section for each section above. Give each a title, then add its questions and pick the question type: Paragraph text, Single line text, Multiple choice, Checkboxes, Body chart or Date (the six types Cliniko offers).
For Multiple choice and Checkboxes, type the options listed in the note column. Add a default answer only where a prompt helps (the range of movement grid, for example).
For the Body chart question, pick Cliniko's body chart templates or upload your own image.
At the bottom, set Print settings so the patient details you want appear when a note is saved as a PDF, then save.
Assign the template to your Initial consultation appointment type so it loads by default.
Or import it: if a colleague or another clinic in Cliniko exports this template (Settings > Treatment note templates > select it > Export), you receive a .json file. Go to Settings > Treatment note templates, click Import, name the template and upload the file.
Cliniko's import also accepts JPG, PNG, WEBP or PDF files up to 5MB and converts them into a template. Unsupported fields are converted to the closest type and formatting may be lost, so check every section after import. Convert a Word document to PDF first.
Write one test note on a test patient, save it as a PDF and check the layout before practitioners use it.

AHPRA: The shared Code of conduct expects your records to be accurate and sufficient for another practitioner to continue care, and to show that the patient gave informed consent. That is why this template has a consent section and a treatment plan that another physio could follow. A template is a prompt, not a record: every note still has to reflect what actually happened in the session.

What this template is built for

A first appointment note has two jobs. It has to support your clinical reasoning on the day, and it has to stand up later: to a colleague who picks up the patient, to a funder asking for progress against baseline, or to a complaint. This template is laid out in the order most physios run an initial assessment, so the practitioner fills it top to bottom without jumping around.

It uses only question types Cliniko supports, so you can build it exactly as written. Where a field would ideally be a number (pain scores, outcome measure scores) it uses single line text, because Cliniko's treatment note questions have no number type.

Why checkboxes and multiple choice matter

Free text is quick to write and hard to use later. Structured fields (area affected, mechanism of onset, referral source, outcome measure used) make notes consistent between practitioners and make audits faster, because the answers are the same words every time.

The red flag screen uses checkboxes for each question asked and cleared. Leave the default answer empty. A template that arrives with every box already ticked is worse than no screen at all, because the record then claims questions were asked when they may not have been.

Consent and the plan

The shared Code of conduct for registered health practitioners, which the Physiotherapy Board of Australia applies, asks for records that let another practitioner continue care and that show the patient gave informed consent. The consent section here records what was explained and what was agreed. Techniques that carry more risk, such as dry needling or spinal manipulation, get their own line in consent notes.

The plan section closes the loop: frequency, the next review, and when the outcome measure will be repeated. That makes the second appointment easier and gives you the numbers funders and insurers ask for.

Sharing it across your clinic

Build the template once in Settings and it becomes a choice for notes written in that Cliniko account. For a second clinic on a separate Cliniko account, export it as a .json file and import it there. Safari tries to open the exported file rather than save it, so Cliniko suggests using Chrome for the export.

Sources

Cliniko treatment note templates support six question types: Paragraph text, Single line text, Multiple choice, Checkboxes, Body charts and Date. Templates are created under Settings > Treatment note templates and can be assigned to an appointment type. Cliniko Help, checked 25 Sep 2026.
Treatment note templates can be exported by an Administrator as a .json file and shared with colleagues, who import it into their own Cliniko account. Cliniko advises using Chrome rather than Safari for the export. Cliniko Help, checked 25 Sep 2026.
Cliniko's template import accepts JSON, JPG, PNG, WEBP or PDF files up to 5MB. Non supported fields or question types are converted to the closest available type and formatting may be removed. Word documents should be converted to PDF first. Cliniko Help, checked 25 Sep 2026.
Body charts are added by setting a question's type to Body Chart, and one body chart question can hold as many charts as needed. Cliniko Help, checked 25 Sep 2026.
The Physiotherapy Board of Australia applies the shared Code of conduct for registered health practitioners, which practitioners have a professional responsibility to apply. Physiotherapy Board of Australia, checked 25 Sep 2026.
Under the Code of conduct, practitioners must keep clear and accurate health records and should always record the information necessary to demonstrate that the patient provided informed consent. Australian Physiotherapy Association (InMotion), checked 25 Sep 2026.