Your treatment plan

[Practice name] · Prepared by [Clinician name], [Profession] · [Date]

Patient

Name: [Patient name] Date of birth: [DD/MM/YYYY]

What we found

Problem: [e.g. right knee pain on stairs and running]

Working diagnosis: [Diagnosis or clinical impression]

Your goals

1. [Goal in the patient's words], by [target date]

2. [Goal], by [target date]

3. [Goal], by [target date]

What we will do

In clinic: [e.g. progressive loading exercises, manual therapy, gait advice]

Expected sessions: [e.g. 4 to 6] at [e.g. weekly, then fortnightly]

Starting: [Start date] Review on: [Review date]

What you will do

[Home exercises, frequency and duration]

[Activity advice, e.g. reduce running to 2 km until the review]

How we will measure progress

[Measure, e.g. pain on stairs 0 to 10, or a validated outcome measure]: [baseline score] today.

Agreement

We have discussed this plan, including the alternatives, and agreed it together. It will be reviewed and may change.

Patient: ____________________ Clinician: ____________________ Date: [DD/MM/YYYY]