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Physical Assessment Checklist Template
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1. Basic Personal Info
Full Name
Full Name
Date of Birth
Date of Birth
Height
Height
Weight
Weight
Phone Number
Phone Number
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2. Overall Physical Health Status
Excellent, fully healthy with no discomfort
Good, occasional minor physical fatigue
Fair, frequent body soreness or sub-health
Poor, have chronic physical symptoms
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3. Cardiopulmonary Function Level
Very good, no breathlessness after exercise
Normal, slight breathlessness after moderate exercise
Weak, obvious breathlessness after mild exercise
Abnormal, need professional medical examination
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4. Daily Physical Mobility & Flexibility
Fully flexible, free limb movement
Slightly stiff, no movement obstacles
Limited joint movement occasionally
Obvious joint pain & movement restriction
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5. Chronic Medical Condition History
No chronic diseases at all
Mild chronic allergy only
Stable chronic underlying disease
Uncontrolled chronic illness
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6. Recent Physical Injury Record (Within 6 months)
No trauma or sports injury
Minor healed bruise/sprain
Unhealed mild body injury
Severe surgery or bone injury
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7. Sleep Quality Condition
High-quality, stable long sleep
Normal sleep, occasional insomnia
Poor sleep, frequent waking up
Severe insomnia & sleep disorder
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8. Regular Medication Situation
No long-term medication
Occasional emergency medicine use
Fixed daily medication needed
Long-term dependent medication
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9. Doctor-restricted Exercise Items
No restricted sports or activities
Forbidden from high-intensity workouts
Forbidden from outdoor strenuous exercise
Need low-intensity activity only
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10. Recent Mental & Fatigue Level
Energetic all day
Mild fatigue after work
Persistent physical tiredness
Severe burnout & physical exhaustion
11. Medical Remarks & Special Notes
Evaluation object score
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