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Physical Therapy Intake Form template

A free physical therapy intake form covering contact details, injury history, pain scales, red-flag health history, and patient goals. Send it as a link before the first visit so evaluations start on time.

Physical Therapy Intake Form

About you

Full name *

Date of birth *

Phone number *

Email address *

Home address *

ZIP code *

Emergency contact

Emergency contact name *

Relationship to you *

Emergency contact phone *

Referral and insurance

How did you hear about us? *

Referring physician name

Insurance provider, or "self-pay"

Your condition

What brings you to physical therapy? *

When did the problem start? *

How did it start? *

Describe the injury or surgery *

Where do you feel symptoms? *

Pain right now (0 = none, 10 = worst imaginable) *

Pain at its worst in the past week *

What makes it worse? *

What makes it better?

Health history

Have you ever been diagnosed with any of these? *

Surgeries in the past 5 years

Current medications

Allergies

Your goals

What would you like to be able to do again? *

I confirm the information above is accurate to the best of my knowledge *

Signature — type your full legal name *

Date signed *

8 questions every PT intake form needs

  1. How the problem started
  2. Where symptoms are felt
  3. Pain now and at its worst
  4. What makes it worse or better
  5. Red-flag health history
  6. Surgeries and medications
  7. Referral and insurance details
  8. The patient's own goals
What's included
  • Full name
  • Date of birth
  • Phone number
  • Email address
  • Home address
  • ZIP code
  • Emergency contact name
  • Relationship to you
  • Emergency contact phone
  • How did you hear about us?
  • Referring physician name
  • Insurance provider, or "self-pay"
  • What brings you to physical therapy?
  • When did the problem start?
  • How did it start?
  • Describe the injury or surgery
  • Where do you feel symptoms?
  • Pain right now (0 = none, 10 = worst imaginable)
  • Pain at its worst in the past week
  • What makes it worse?
  • What makes it better?
  • Have you ever been diagnosed with any of these?
  • Surgeries in the past 5 years
  • Current medications
  • Allergies
  • What would you like to be able to do again?
  • I confirm the information above is accurate to the best of my knowledge
  • Signature — type your full legal name
  • Date signed
Prefer paper? Print it

Download this form as a PDF or Word file — free, no account. When you're ready, send the same form as a link so nobody retypes a clipboard.

This template is a starting point, not legal or medical advice, and using it does not by itself make your practice HIPAA compliant. To collect patient health information on TendForm, use the HIPAA plan with a signed Business Associate Agreement, and have your own counsel review consent and policy wording.