Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Physical Therapy Intake Form
Physical Therapy Intake Form Please complete this form prior to your first appointment. Accurate information helps your therapist create a treatment plan tailored to your recovery goals.
Full Name *
Date of Birth *
____ / ____ / ________
Email Address *
Phone Number *
Referring Physician
Diagnosis
Injury Details & Functional Assessment Provide information about your condition so we can evaluate your needs and track your progress.
Primary Complaint *
How Did the Injury Occur? *
Date of Onset *
____ / ____ / ________
Current Pain Level (1-10) *
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
Affected Body Area *
- Neck
- Shoulder
- Elbow
- Wrist
- Hand
- Upper Back
- Lower Back
- Hip
- Knee
- Ankle
- Foot
Functional Limitations
- Walking
- Sitting
- Standing
- Lifting
- Sleeping
- Climbing Stairs
- Driving
- Work Activities
Have You Had Physical Therapy Before? *
- Yes
- No
Goals for Therapy *
Current Exercise Routine
Surgical History
Current Medications
Physical Therapy Intake Form template from formisoft.com. formisoft.com/intake-templates/physical-therapy-intake