Rehabilitation Intake Form
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Rehabilitation Intake Form
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The Rehabilitation Intake Form is designed to capture a complete clinical picture of patients entering rehabilitation programs following injury, surgery, stroke, or other medical events that have impacted their functional independence. It documents the patient's prior level of function, current functional status across multiple domains, and the specific rehabilitation goals that will guide their treatment plan. This thorough baseline assessment enables therapists and physiatrists to develop individualized care plans that target the areas of greatest need.
This template covers the full spectrum of rehabilitation assessment domains including mobility and ambulation status, activities of daily living (ADL) independence levels, cognitive function screening, communication abilities, and pain evaluation. It also captures critical contextual information such as the referring provider, diagnosis and date of onset, current medication regimen, and caregiver availability, all of which influence rehabilitation planning and expected outcomes.
Suitable for inpatient rehabilitation facilities, skilled nursing facilities, outpatient physical therapy clinics, and home health rehabilitation programs, this form aligns with CMS Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data elements. It provides rehabilitation teams with the structured documentation needed to justify medical necessity, track functional improvement over time, and coordinate seamless transitions between levels of care.
What's included
- Patient demographics and referring provider information
- Diagnosis, date of onset, and prior functional baseline
- Mobility, ADL, cognitive, and communication assessments
- Pain evaluation and current medication documentation
- Individualized rehabilitation goal-setting section
- Caregiver availability, insurance authorization, and home environment review
- Structured medication list with dosage and frequency tracking
Who uses this template
- Inpatient rehabilitation facility admissions following stroke, TBI, or spinal cord injury
- Outpatient physical and occupational therapy program intake evaluations
- Skilled nursing facility rehabilitation program enrollment assessments
- Home health rehabilitation service initiation and baseline documentation
All form fields
18 fields across 3 pages. Customize any field after signing up.
How to use the Rehabilitation Intake Form
Getting started with this template takes just a few minutes. Sign up for a free Formisoft trial, then select the Rehabilitation 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 Rehabilitation 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 18 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 Rehabilitation Intake Form HIPAA compliant?
Yes. All Formisoft templates, including the Rehabilitation 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 18 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 Rehabilitation 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
Sign up and start customizing the Rehabilitation Intake Form for your practice. Set up in minutes.
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