Physical Therapy Intake Form: Essential Fields for PT Clinics

Physical therapy intake is uniquely functional. Unlike a general medical intake, you're not just collecting history. You're trying to understand what a patient can and can't do right now, what their baseline was, and what "better" looks like to them.

A strong PT intake form captures all of this before the evaluation begins, so your first session is treatment-focused rather than paperwork-focused.

Demographics and Insurance

Standard fields: name, date of birth, contact information, emergency contact. For PT specifically, insurance and referral information are critical, as many payers require a physician referral, and verifying this before the appointment prevents wasted visits.

Include:

• Primary insurance and member ID
• Referring physician name and NPI
• Referral or prescription upload (file upload field)
• Workers' compensation or auto accident information, if applicable

The referral question should trigger conditional fields. If the patient selects workers' comp or auto accident, show fields for claim number, adjuster contact, and date of injury.

Reason for Visit and Injury Details

Get specific:

• Primary complaint or diagnosis
• How and when the injury or condition started
• Was there a specific incident (fall, accident, sports injury) or gradual onset?
• Has the condition been treated before? By whom?
• Previous physical therapy for this or related conditions

Patients who've had PT before can tell you what worked and what didn't, which is valuable information that shapes your treatment plan.

Pain Assessment

Pain is the universal language of PT intake. Capture it with structure:

• Pain location: a body diagram or body map field lets patients point rather than describe. "The outside of my left knee" is clearer when they can tap on an image.
• Pain scale: 0-10 numeric rating scale, at rest and with activity
• Pain quality: sharp, dull, burning, aching, throbbing (checkbox selection)
• Aggravating factors: what makes it worse
• Relieving factors: what makes it better
• Pain pattern: constant, intermittent, worse in morning/evening

This structured data is immediately useful for your initial evaluation and becomes a measurable baseline for progress tracking.

Functional Limitations

This is where PT intake really differentiates itself:

• Activities the patient can't currently perform
• Activities that are limited or modified
• Impact on work, daily tasks, sleep, and recreation
• Assistive devices currently in use (brace, cane, walker)
• Mobility status (independent, limited, needs assistance)

Ask patients to rate their function on a simple scale. "On a scale of 0-100, where 100 is your normal activity level, where are you now?" gives you a quick functional baseline.

Treatment Goals

What does the patient want to achieve? This is often different from what the diagnosis suggests. A runner with knee pain wants to run again. A desk worker with back pain wants to sit through a meeting without shifting every two minutes.

Capture goals in the patient's own words. This drives patient engagement and gives you clear outcomes to work toward.

Surgical and Medical History

Past surgeries (especially orthopedic), current medications, relevant medical conditions (diabetes, osteoporosis, cardiac conditions), and any precautions or contraindications.

Include imaging history: has the patient had X-rays, MRI, or CT scans for this condition? Can they upload the results?

Building a PT Intake Form That Works

Formisoft makes this straightforward. The AI builder can generate a PT-specific intake form as a starting point, and you can customize it with drag-and-drop. Use conditional logic to show workers' comp fields only when relevant, multi-page layout to keep sections organized, and file upload fields for referrals and imaging results.

Send intake forms to patients before their first visit via email. They arrive with everything documented, and you spend your evaluation time on hands-on assessment instead of clipboard questions.

Build your PT intake form with Formisoft, try it free.