Physical Therapy Intake Form

Asks about referring physician, diagnosis, and primary complaint. Built for physical therapy clinics and rehab centers.

Questions: 18
Pages: 2
Time: about 5 min

E-signature

Your practice

Page 1 of 2

Full Name

Date of Birth

Email Address

Phone Number

Referring Physician

Diagnosis

Live preview. Tap through it like a patient.

Who it is for

Physical therapy clinics and rehab centers
Sports medicine practices
Occupational therapy offices
Post-surgical rehabilitation programs

Formisoft for Mental Health Formisoft for Physical Therapy

What's inside

Page 1

Full NameText · Required
Date of BirthDate · Required
Email AddressEmail · Required
Phone NumberPhone · Required
Referring PhysicianText
DiagnosisText

Page 2

Primary ComplaintLong Text · Required
How Did the Injury Occur?Long Text · Required
Date of OnsetDate · Required
Current Pain Level (1-10)Multiple Choice · 10 choices · Required
Affected Body AreaCheckbox · 11 choices · Required
Functional LimitationsCheckbox · 8 choices
Have You Had Physical Therapy Before?Multiple Choice · 2 choices · Required
Goals for TherapyLong Text · Required
Current Exercise RoutineLong Text
Surgical HistoryLong Text
Current MedicationsLong Text
Patient SignatureE-Signature · Required

From form to a ready patient

01
Make it yours
Reword, reorder, or add to the Physical Therapy Intake Form, and add your logo.
02
Patients finish it at home
A secure link by text or email, filled out on their phone before the visit. No app.
03
Your team sees who is ready
Each visit shows as ready once its forms are in. Answers land on the patient record.

Related templates

All templates

Questions

Responses are encrypted, only your team can see them, and a BAA is included.

Yes. You can add, remove, reorder, or reword any of the 18 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.

Yes. Attach the form to a visit type and every patient who books gets it right away, with a reminder before the visit if it is not done. Your calendar shows which visits are ready.

Send it before the visit, so patients arrive ready.

Book a short call and we will set up the Physical Therapy Intake Form for your practice, ready to send before the next visit.

BAA included · We set up your front desk

Use this template