Physical Therapy Intake Form — shared by the community
Dev A. shared this 27-question build with 3 conditional rules already wired up. Test it below, then take a copy.
A ready-to-use healthcare & clinical form for small teams who need a reliable intake process: 27 questions, 3 pages, 3 conditional rules.
- Shared by
- Dev A. · Freelance consultant
- Questions
- 27
- Replies
- 14
- Copies taken
- 263
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Live preview and test console
This is the real form. Answer it to test the flow — nothing is sent or stored.
Page 1 of 3 — Patient and functional priorities
This template runs as a straight sequence — no branching rules.
Works for you? Take Dev A.'s copy into your own workspace — questions, rules and settings included.
Who this template is for
Physical Therapy Intake Form is built for small teams who need a reliable intake process who need to collect the same complete information from everyone.
- Small teams who need a reliable intake process working in healthcare & clinical.
- Teams who need to collect the same complete information from everyone without writing code or paying for a custom build.
- Anyone replacing chasing missing details over email with one structured record per enquiry.
- Respondents are the people you send it to — the form asks them 27 questions across 3 screens.
- Mobile-heavy audiences, thanks to the one-question-per-screen card layout.
Why this form is useful
It removes the cost of chasing missing details over email and turns each submission into a record your team can act on immediately.
- 13 questions are required, so submissions arrive complete instead of needing a follow-up email.
- It collects a verified email address so replies and confirmations land.
- It captures a phone number for urgent follow-up.
- It records a signature you can keep as proof of agreement.
- It pins the request to a specific date.
- Conditional logic hides 3 questions until they are relevant — shorter forms convert better than long ones.
- Splitting the form across 3 pages keeps each screen short and shows respondents how much is left.
- Every response is stored, searchable and exportable, so nothing depends on one person's inbox.
How to use this template
From copy to live form is a few minutes of work, and every step is reversible.
- 1Press “Use this template” — a fresh copy of Physical Therapy Intake Form lands in your workspace, ready to edit.
- 2Rename or delete any question, and change what is required. Nothing here is fixed.
- 3Open Notifications and add the email addresses that should be alerted on each submission; add an auto-reply to the respondent if the form collects an email address.
- 4Publish it, then either share the link directly or paste the embed snippet into your site — the embedded form resizes to fit and loads no marketing or advertising trackers.
- 5Watch responses land in Submissions, where you can filter, label and export them to CSV or PDF.
Logic and conditions blueprint
Exactly how this form behaves as it is answered — 3 conditional rules ship with it.
- Features conditional validation: if “Do you have a referral for this visit?” is Yes, “Referring clinician and referral details” becomes mandatory before the form can be sent.
- Features conditional validation: if “Have you had a related surgery or procedure?” is Yes, “Procedure and approximate date” becomes mandatory before the form can be sent.
- Features conditional validation: if “Do you need access or communication support?” is Yes, “Support requested for the evaluation” becomes mandatory before the form can be sent.
- All 3 rules are editable in the Logic tab, and the built-in checker warns about rules that contradict each other.
What this form asks
Page 1 — Patient and functional priorities
- Patient full namerequired
- Email addressrequired
- Phone number
- Date of birthrequired
- Emergency contact name and relationship
- Emergency contact phone
- Main concern and when it beganrequired
- Activities currently limitedrequired
- What would you like to do more comfortably?required
- What makes symptoms better or worse?
Page 2 — Clinical background
- Relevant health conditions and current medications
- Have you had a related surgery or procedure?required
- Procedure and approximate date
- Previous treatment and response
- Mobility aids or other support currently used
- Do you have a referral for this visit?required
- Referring clinician and referral details
- Restrictions or guidance already provided by a clinician
Page 3 — Appointment preparation
- Do you need access or communication support?required
- Support requested for the evaluation
- Preferred evaluation date
- Would you like a billing discussion before the visit?required
- Questions for the physical therapist
- Evaluation intake acknowledgmentrequired
- Patient or authorized representative signaturerequired
- Representative name and authority, if applicable
- Date completedrequired
Conditional logic in this build
- When “Do you have a referral for this visit?” is Yes, require “Referring clinician and referral details”.
- When “Have you had a related surgery or procedure?” is Yes, require “Procedure and approximate date”.
- When “Do you need access or communication support?” is Yes, require “Support requested for the evaluation”.
Questions about this shared form
Does a referral answer determine eligibility?
No. Referral, access and payment requirements depend on the situation and must be confirmed by the clinic.
Can this replace the initial evaluation?
No. It prepares the therapist's interview; examination, clinical judgment and treatment planning happen separately.
Should full insurance details go here?
This version requests a billing conversation instead. Collect necessary policy information through a process reviewed for your practice.
How does Medical History Form relate?
Medical History Form can support a broader background record, while this intake centers functional limits and rehabilitation goals.
Is the Physical Therapy Intake Form template free to use?
Yes. You can preview and test Physical Therapy Intake Form on this page without an account, and take a copy into your own HelloForms workspace on the free plan. There is nothing to install and no card required to publish it.
What does the Physical Therapy Intake Form template ask for?
It asks 27 questions across 3 pages, 13 of which are required. Every question is listed in full further down this page, and each one can be renamed, reordered, made optional or deleted after you copy the template.
Can I edit the Physical Therapy Intake Form form after copying it?
Yes — the copy is entirely yours. Change wording, add or remove questions, switch between the classic and card layouts, restyle it to match your brand, and set who gets notified on each submission.
How does the conditional logic in this healthcare & clinical form work?
3 conditional rules ship with the template: Features conditional validation: if “Do you have a referral for this visit?” is Yes, “Referring clinician and referral details” becomes mandatory before the form can be sent. Features conditional validation: if “Have you had a related surgery or procedure?” is Yes, “Procedure and approximate date” becomes mandatory before the form can be sent. Features conditional validation: if “Do you need access or communication support?” is Yes, “Support requested for the evaluation” becomes mandatory before the form can be sent. All rules are editable in the Logic tab.
Where do responses to the Physical Therapy Intake Form form go?
Submissions land in your workspace under Submissions, where you can search, filter, label and export them to CSV or PDF. You can also email a notification to your team on every submission and send the respondent an auto-reply.
Can I embed the Physical Therapy Intake Form form on my own website?
Yes. Publish the form and paste the embed snippet into any page or share the direct link. The embedded form resizes to fit its container and loads no advertising or marketing trackers inside the iframe.
Is the signature on this form legally usable?
The template captures a drawn signature and stores it with the submission, along with the timestamp, so you keep evidence of who agreed and when. Whether that is sufficient depends on your jurisdiction and the agreement itself.
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