formisoft

Rehabilitation Intake Form

Asks about referring provider, diagnosis/condition, and date of onset/injury. Built for inpatient rehabilitation facility admissions following stroke, TBI, or spinal cord injury.

Questions
18
Pages
2
Time
about 5 min

Includes

  • Medication list
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Your practice

Rehabilitation Intake Form

Page 1 of 2 · Your information

Live preview. Tap through it like a patient.

Who it is for

  • 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

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What's inside

Page 1 · Your information

  1. Full NameText · Required
  2. Phone NumberPhone
  3. Email AddressEmail
  4. Referring ProviderText
  5. Diagnosis/ConditionLong Text

Page 2 · Additional details

  1. ADL Independence LevelLong Text
  2. Cognitive AssessmentLong Text
  3. Communication StatusLong Text
  4. Pain AssessmentLong Text
  5. Current MedicationsMedications

From form to a ready patient

  1. The Formisoft form builder with editable questions and required toggles

    01

    Make it yours

    Reword, reorder, or add to the Rehabilitation Intake Form, and add your logo.

  2. A patient filling out a Formisoft form on a phone

    02

    Patients finish it at home

    A secure link by text or email, filled out on their phone before the visit. No app.

  3. The Formisoft dashboard showing how many of today's patients are ready

    03

    Your team sees who is ready

    Each visit shows as ready once its forms are in. Answers land on the patient record.

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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 Rehabilitation Intake Form for your practice, ready to send before the next visit.

BAA included · We set up your front desk

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