Clinidiary

← All resources / Treatment-note templates

Low back pain assessment template

Screens for serious causes first, stratifies risk, and records a plan built on reassurance and activity.

What it is built on

  • Assessment, red flags and first-line care. NICE guideline NG59, Low back pain and sciatica in over 16s (2016, updated 2020)
  • Australian standard of care. Australian Commission on Safety and Quality in Health Care, Low Back Pain Clinical Care Standard (2022)
  • Risk stratification. STarT Back Screening Tool, Keele University (Hill et al., 2008)

How to use it: Free Evidence-Based Physiotherapy Note Templates

Subjective

  1. History of the presenting problem Written answer Onset, mechanism, duration, behaviour over 24 hours, aggravating and easing factors.
  2. Pain now (0–10) Scale 0 to 10
  3. Pain at worst in the last week (0–10) Scale 0 to 10
  4. What it stops them doing Written answer Work, sleep, sport, daily tasks.
  5. Patient's goals Written answer In their words.

Serious causes screened

  1. Ask every patientA yes needs a clear plan, and some need same-day medical review.
  2. Cauda equina symptoms: saddle numbness, new bladder or bowel change, or leg symptoms on both sides Tick box Emergency referral the same day.
  3. History of cancer, or unexplained weight loss Tick box
  4. Fever, feeling unwell, recent infection, immune suppression or injecting drug use Tick box
  5. Significant trauma, long-term steroid use or known osteoporosis Tick box
  6. Progressive or widespread weakness or numbness Tick box
  7. None of the above Tick box

Risk and leg symptoms

  1. STarT Back risk group Choose one: Low · Medium · High · Not done Low risk: advice and reassurance. Medium: physiotherapy. High: physiotherapy that addresses beliefs and distress as well.
  2. Leg symptoms Choose one: None · Referred above the knee · Below the knee (possible radicular pain)
  3. Beliefs, worries and stress Written answer Fear of movement, work worries, sleep.

Objective

  1. Body chart Body chart, drawn on
  2. Lumbar movement and observation Written answer
  3. Neurological screen Written answer Myotomes, dermatomes, reflexes, straight leg raise or slump where leg symptoms.
  4. Palpation and other tests Written answer

Assessment and plan

  1. Clinical impression Written answer
  2. What was explained to the patient Written answer
  3. Treatment today Written answer
  4. Home program given Written answer
  5. Plan and expected number of visits Written answer
  6. Referral or imaging needed? Choose one: No · Yes — to GP · Yes — imaging · Yes — specialist · Yes — urgent / emergency
  7. Advised to stay active and that imaging is not routinely needed Tick box NICE NG59 recommends against routine imaging without a specific clinical reason.

A starting point, not clinical advice. Check that it fits your patients, your practice and the rules where you work before you use it.