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Physical Therapy Intake Form
Intake

Physical Therapy Intake Form

2 pages•15 fields•HIPAA-ready
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Physical Therapy Intake Form
Patient Information
Referring Physician
Injury/Condition Description
Date of Injury/Onset
Pain Location (Body Map)
Select...
Pain Level (VAS 0-10)
Functional Limitations
Previous PT/Treatment
Treatment Goals
Insurance Authorization
Insurance carrier & policy
Submit
Use this template

The Physical Therapy Intake Form is designed for PT clinics, sports medicine practices, and rehabilitation centers. It captures the specialized information physical therapists need to develop an effective treatment plan: detailed injury or condition description, mechanism of injury, onset date, pain assessment using the Visual Analog Scale (VAS), functional limitations, and previous treatments.

The form includes body map pain location selection, allowing patients to precisely indicate where they experience symptoms. Functional limitation checklists cover activities of daily living, work-related tasks, and recreational activities, giving the therapist a clear picture of the patient's current functional status.

Referring physician information and insurance authorization details are captured upfront, streamlining the administrative process. Treatment goals are set collaboratively with the patient during intake, establishing measurable outcomes from day one. This template is also suitable for occupational therapy, speech therapy, and cardiac rehabilitation programs with minor customization.

What's included

  • Injury description and mechanism of onset
  • VAS pain scale and body map selection
  • Functional limitations checklist
  • Previous treatment and therapy history
  • Treatment goals and expectations
  • Referring physician and insurance authorization
  • Insurance information collection with carrier and policy details

Who uses this template

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

All form fields

10 fields across 2 pages. Customize any field after signing up.

Patient InformationText
Referring PhysicianText
Injury/Condition DescriptionLong Text
Date of Injury/OnsetDate
Pain Location (Body Map)Dropdown
Pain Level (VAS 0-10)Multiple Choice
Functional LimitationsCheckbox
Previous PT/TreatmentLong Text
Treatment GoalsLong Text
Insurance AuthorizationInsurance Info

Use this template

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$79.99/mo · 14-day free trial · HIPAA compliant

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