Unlock hundreds more features
Save your Form to the Dashboard
View and Export Results
Use AI to Create Forms and Analyse Results

Forgot Password?
Get Started
OR
Sign UpLogin With Facebook
Sign UpLogin With Google

Physical Therapy Intake Form Template

Streamline patient onboarding with an effective intake process

Are you struggling to collect critical patient information for physical therapy? This Physical Therapy Intake Form Template is designed for therapists who want to streamline the onboarding process and accurately assess patient needs. By using this template, you can improve patient satisfaction, enhance data collection efficiency, and ensure compliance with medical standards. With clear, patient-friendly questions covering personal, lifestyle, and medical histories, your team will gain valuable insights into each patient's condition. Start using the live template today to simplify your intake process.

Use this Template (FREE) Live Preview
Full legal name
Date of birth
Email address
Mobile phone
Street address (include city, state, ZIP)
Emergency contact full name
Emergency contact relationship to you
Emergency contact phone
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Do you have health insurance for this visit?
Yes
No
Insurance company
Member/Subscriber ID
Policy holder name
Referring provider name (if any)
Policy holder relationship to patient
Self
Spouse
Parent/Guardian
Not applicable
Other
Please Specify:
What is the primary reason for your visit?
When did your symptoms or injury begin?
How did this begin?
Sports activity
Work-related
Auto accident
Home or daily activity
Post-surgical
No specific cause
Other/Not sure
Is this related to a work injury or auto accident?
Work injury
Auto accident
No
Not sure
Which body regions are affected?
Current pain level
Worst pain in the past week
Which words describe your symptoms?
Please Specify:
What activities or positions make symptoms worse?
What helps reduce your symptoms?
Which daily activities are currently difficult?
Please Specify:
Do you use any assistive devices?
None
Brace/support
Cane
Crutches
Walker
Wheelchair
Sling
Orthotics
Other
Please Specify:
Have you had imaging for this issue?
None
X-ray
MRI
CT scan
Ultrasound
Not sure
What treatments have you already tried for this issue?
Have you fallen in the past year?
Yes
No
Please indicate any current or past conditions
Please Specify:
Allergies
No known allergies
Medication allergies
Latex allergy
Adhesive allergy
Food allergies
Other
Please Specify:
List current medications (name and dose if known)
Prior surgeries or hospitalizations (include dates if known)
Are you currently pregnant?
Yes
No
Not applicable
Prefer not to say
Tobacco use
Never
Former
Current daily
Current some days
Prefer not to say
Employment status
Employed full-time
Employed part-time
Self-employed
Student
Homemaker
Retired
Unemployed
Prefer not to say
What are your top goals for therapy?
Typical job physical demands
Mostly sitting
Light physical (frequent standing/walking)
Moderate physical (frequent lifting up to 25 lbs)
Heavy physical (regular lifting over 25 lbs)
Not applicable
I authorize evaluation and treatment by the physical therapy provider
Strongly disagree
Disagree
Neither
Agree
Strongly agree
I acknowledge receipt or availability of the Notice of Privacy Practices (HIPAA)
Yes
No
I accept financial responsibility for charges not covered by insurance
Yes
No
Signature (type your full name)
Signature date
I acknowledge the clinic cancellation/no-show policy
Yes
No
{"name":"Full legal name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Full legal name, Date of birth, Email address","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration depicting a physical therapy intake form with various sections and fields for patient information

When to use this form

Use this digital intake before a first PT visit to capture history, pain, goals, red flags, and consent. It helps outpatient clinics, hospital rehab, and solo practitioners triage new patients after surgery, a sports injury, a fall, or a flare of chronic back or neck pain. You can screen for contraindications (e.g., fractures, blood thinners, dizziness), insurance details, and attachments like imaging or referrals. Patients complete it on any device, so you cut waiting-room paperwork and start the evaluation focused and on time. For ongoing care, pair it with a Session check-in form to track pain, function, and home-exercise adherence between visits.

Must Ask Physical Therapy Intake Questions

  1. What is your primary reason for seeking physical therapy and your top goals?

    Clear goals let you prioritize tests and treatments that matter most to the patient. If your clinic also screens for mood or stress that can amplify pain, pair this with a Mental health intake form to coordinate care.

  2. When did your symptoms start, and what activities make them better or worse?

    Onset and aggravating/relieving factors reveal the stage of healing and guide load management. This helps you choose safe progressions and avoid provoking a flare.

  3. Where is your pain or limitation, and how severe is it (0-10) at rest and with activity?

    Baseline severity and irritability help you set expectations and monitor change. Consistent scales improve decisions on visit frequency and home exercise dosing.

  4. List relevant medical history, surgeries, medications, and any allergies or sensitivities.

    These details uncover red flags and contraindications (e.g., anticoagulants, osteoporosis, tape/latex allergy). You reduce risk and tailor manual therapy, modalities, and precautions.

  5. What are your work duties, daily activities, and sports or hobbies you want to return to?

    Functional demands define objective measures and discharge criteria that matter in real life. This makes your plan specific, measurable, and tied to the tasks the patient values.

More Forms

Copy/Edit Form Send to Recipients Make a Form w/AI Form Builder Must Ask Questions
  • 100% Free - No Catches
  • Collect Responses Today
  • Tailor to your Look & Feel