Physical Therapy Intake Form
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Physical Therapy Intake Form
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The Physical Therapy Intake Form is designed for PT clinics, sports medicine practices, and rehabilitation centers. It captures the specialized information physical therapists need to develop an effective treatment plan: detailed injury or condition description, mechanism of injury, onset date, pain assessment using the Visual Analog Scale (VAS), functional limitations, and previous treatments.
The form includes body map pain location selection, allowing patients to precisely indicate where they experience symptoms. Functional limitation checklists cover activities of daily living, work-related tasks, and recreational activities, giving the therapist a clear picture of the patient's current functional status.
Referring physician information and insurance authorization details are captured upfront, streamlining the administrative process. Treatment goals are set collaboratively with the patient during intake, establishing measurable outcomes from day one. This template is also suitable for occupational therapy, speech therapy, and cardiac rehabilitation programs with minor customization.
What's included
- Injury description and mechanism of onset
- VAS pain scale and body map selection
- Functional limitations checklist
- Previous treatment and therapy history
- Treatment goals and expectations
- Referring physician and insurance authorization
- Insurance information collection with carrier and policy details
Who uses this template
- Physical therapy clinics and rehab centers
- Sports medicine practices
- Occupational therapy offices
- Post-surgical rehabilitation programs
All form fields
12 fields across 2 pages. Customize any field after signing up.
How to use the Physical Therapy Intake Form
Getting started with this template takes just a few minutes. Sign up for a free Formisoft trial, then select the Physical Therapy Intake Form from the template library. The form is ready to use immediately, but you can customize every field, add your practice logo, and adjust the layout to match your workflow.
Setup steps
- 1Choose the template. Find the Physical Therapy Intake Form in the template library and click “Use this template” to add it to your account.
- 2Customize fields. Add, remove, or reorder any of the 12 fields. Set fields as required or optional based on your practice needs.
- 3Brand it. Upload your logo, pick your colors, and add a custom welcome message so patients see your practice identity.
- 4Share with patients. Send the form via SMS, email, or embed it on your website. Patients complete it on any device before their visit.
- 5Review submissions. Responses appear in your dashboard in real time. Patient records are created automatically from the data collected.
Frequently asked questions
Is the Physical Therapy Intake Form HIPAA compliant?
Yes. All Formisoft templates, including the Physical Therapy Intake Form, are HIPAA compliant. Data is encrypted with 256-bit AES at rest and TLS 1.3 in transit. A Business Associate Agreement (BAA) is included on every plan.
Can I customize the fields in this template?
Absolutely. You can add, remove, reorder, or modify any of the 12 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.
How do patients fill out this form?
Patients receive a link via SMS, email, or QR code. They complete the form on their phone, tablet, or computer before their appointment. No app download required.
Can I send this form automatically before appointments?
Yes. Formisoft's workflow automation can send intake forms automatically when an appointment is booked. You can set the timing (e.g., 48 hours before the visit) and include reminders for patients who haven't completed it.
Does this template work on mobile devices?
Yes. The Physical Therapy Intake Form is fully responsive and works on any device. Most patients complete intake forms on their phone, so every template is optimized for mobile-first use.
Start with this template
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