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  • Zak Bartley

Physical Therapy Patient Intake Form Template

Patient intake forms are a must-have for every physical therapy clinic. In fact, you may even be required by law to have one. However, if you are busy starting your practice or need an update, then use this physical therapy patient Intake form template to create one and guarantee better patient care and services.


Below you can download a Free Intake Form Template for Physical Patients.

Patient intake forms are a must-have for every physical therapy clinic. In fact, you may even be required by law to have one.


However, if you're just getting started or want to revamp your intake paperwork, then this template will help.


Below you can download a Free Intake Form Template for Physical Therapy Patients.

Patient Form Template



What is a Physical Therapy New Patient Intake Form?

One of the most important documents your office will use is the physical therapy patient intake form. This document allows you to assess a patient's medical history, past treatment, and current condition. Intake forms also uncover details about a patient's insurance coverage and any prescription drugs they take. The information discovered on an intake form can be an essential tool in helping you develop an effective treatment plan for your patients.


Patient intake forms help your physical therapy practice make sure that each patient understands his or her obligations and gives consent to a course of treatment. Treatment consent, privacy practices and statement of financial obligations will be clearly communicated with patients.


The forms will be used to establish a system of accountability and responsibility between you and your patients. It is important to keep in mind that when patients sign their consent form, they are agreeing to participate in a course of treatment that may include the use of physical therapy modalities such as ultrasound, electrical stimulation and manual therapy.


What are the requirements for a Physical Therapy Intake Form?

A patient intake form, like an agreement between two parties, must state and clearly define all expectations—as well as the patient's current health conditions and history.

Let's look at the essential information that you must collect using your intake form.


1. Patient Information

The first section of the form should contain all relevant information about your patient that is important when it comes to contacting them. Here’s a list of personal questions you can include in yours:

  1. First Name

  2. Middle Name

  3. Last Name

  4. Sex at Birth

  5. Gender Identity

  6. Date of Birth

  7. Home Phone Number

  8. Mobile Phone Number

  9. Address

  10. Email

  11. Preferred method of contact (email, sms, or phone)

2. Demographic Data

Collecting demographic data about the people you treat can help identify risks, lifestyle, and give insight into treatment possibilities.

  1. Age

  2. Marital Status (Single, Married, Separated, Divorced, Widower)

  3. Employment Status (Employed, Unemployed, Part-time/Contractual worker, Self-Employed)

3. Medical History and Current Condition

Gathering information about your patients’ health and medical history is an essential part of providing quality care. While you want to ask all the appropriate questions, make sure that they are not too long or inconvenient so that people will actually fill them out!

  1. Injury or Major Complaint:

  2. Start Date

  3. Cause

  4. Location of Injury

  5. How would you describe your pain?: Sharp/Shooting/Dull/Sore/Stiff

  6. What is the current pain rating? (0-10):

  7. What is the worst pain rating? (0-10):

  8. What is the best pain rating? (0-10):

  9. Pre-existing health conditions (Check all that apply)

  10. Are any of these conditions hereditary? (If yes, give details)

  11. List of surgeries, if any (Mention the year)

  12. Allergies, if any (Check all that apply)

  13. Are you currently pregnant? (Yes or No; If yes, mention due date)

  14. Do you currently smoke? (Yes or No)

  15. How often do you drink? (Never, Rarely, Socially, Regularly)

  16. Do you consume any illicit drugs? (Yes or No; If yes, give details)

  17. Any previous injuries? (Yes or No; If yes, give details)

4. Payment Details

Collecting insurance and payment details ahead of time will mitigate billing risks and insurance eligibility problems. Because this information is sensitive, it is recommended to use a secure digital patient forms software rather than collecting it on paper.

  1. Do you have insurance? (Yes or No; If yes, give details)

  2. Medicare (Yes or No)

  3. Picture of insurance card (front and back)

  4. How would you like to pay for your treatment? (credit card, invoice, etc.)

  5. Credit Card details

  6. Picture of Drivers License or ID card

5. Consent, Obligations and Signature

Intake forms act as an agreement or understanding between you and your patient. These obligations and authorizations should be clear to both parties. Consider the following when creating your intake forms.

  1. Financial Policy

  2. Cancellation Policy

  3. Notice of Privacy Practices (NOPP)

  4. Release of Protected Health Information

  5. Consent for Treatment and Procedures


Digital Patient Intake Forms for Physical and Occupational Therapy

Not all therapy intake forms are created equal. The

found in a recent study that, “81% of patients surveyed prefer digital forms over paper and clipboards, with 83% stating they want to complete forms online before coming into the healthcare facility.”


Digital patient intake forms replaces the need for paper intake forms. Patient forms software enables patients to submit information electronically, which is then seamlessly integrated with the practice’s electronic health record (EHR) and practice management software.


A digital platform has substantial advantages of its paper predecessor including:

  1. Faster Intake

  2. Not printing/scanning

  3. No manual data entry (typing) into your EHR

  4. Automatic Insurance Eligibility

  5. Improved Patient Experience

Learn more about Digital Patient Intake Forms for Physical Therapy or speak with one our representatives today.