Physical Therapy Intake Form
Capture functional limitations, symptom history, referral details and access needs so a physical therapist can prepare for an initial patient evaluation.
A ready-to-use healthcare & clinical form for small teams who need a reliable intake process: 27 questions, 3 pages, 3 conditional rules.
- Questions
- 27
- Pages
- 3
- Layouts
- classic · card
- Time to complete
- ≈ 10 min
- Conditional rules
- 3
Searches this template answers
- physical therapy intake form
- physical therapy patient questionnaire
- rehabilitation initial intake template
- PT new patient registration
- functional limitations questionnaire
- physical therapist consultation form
Also filed under
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.
Compliance checklist
- Payment items priced — passingEvery payment question charges a real amount, so a submission always records a payment.
- Conditional logic resolves — passingEvery rule points at a question or page that exists in this template.
- Medical disclaimer present — passingThis form does not provide medical advice, diagnosis or treatment. Information you share here is not a substitute for care from a qualified clinician. In an emergency, contact your local emergency service immediately.
- Question labels unique — passingLogic and exports address questions by label, so duplicates are ambiguous.
What happens after submit: nothing is stored in this preview. On your own copy, every response triggers an instant email notification and lands in your response dashboard, ready to export or forward.
Happy with it? Take a copy into your workspace — every question, rule and setting comes with it.
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.
About this template
The most useful opening question in rehabilitation is often about an ordinary task: climbing stairs, returning to a shift or lifting a child. This physical therapy intake puts those functional priorities alongside the symptom history so the first evaluation has a clear starting point. Patients describe when the issue began, what changes it and which activities they want to regain. The form also collects relevant procedures, current medications and prior care without asking the patient to choose a diagnosis. Referral details appear only as a follow-up when a referral exists; the form makes no assumption about whether one is required for a particular visit or payment arrangement. Contact information, emergency contact and access needs help the clinic organize the appointment, while a request for billing discussion avoids collecting full payment or policy credentials in a general intake. A signed acknowledgment explains that clinical evaluation and any treatment consent remain separate steps. This is for outpatient practices gathering information ahead of an initial assessment, not a remote examination, an exercise prescription or confirmation of insurance coverage. Staff should route changes or unanswered concerns to the clinician rather than letting the submission automatically authorize treatment.
What this form asks
Every question is editable — rename it, make it optional, or delete it entirely.
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
27 questions in total.
How the form changes as it's filled in
This template ships with 3 conditional rules, grouped into 3 behaviours driven by 3 questions. Everything below is already set up — edit or delete any rule once the template is in your workspace.
Driven by “Do you have a referral for this visit?”
- Makes answers required
If “Do you have a referral for this visit?” is Yes, “Referring clinician and referral details” becomes required before the form can be submitted.
Driven by “Have you had a related surgery or procedure?”
- Makes answers required
If “Have you had a related surgery or procedure?” is Yes, “Procedure and approximate date” becomes required before the form can be submitted.
Driven by “Do you need access or communication support?”
- Makes answers required
If “Do you need access or communication support?” is Yes, “Support requested for the evaluation” becomes required before the form can be submitted.
Set it up step by step
- 1
Start with meaningful activities
Keep the functional questions prominent so the clinician can understand the patient's priorities before reviewing administrative details.
- 2
Check referral arrangements separately
Confirm your clinic's referral and payment requirements rather than assuming the questionnaire settles them.
- 3
Give the therapist review time
Deliver the history and reported restrictions ahead of the first evaluation through your approved workflow.
- 4
Confirm practical arrangements
Send location, accessibility and billing information after staff have checked the appointment request.
Mistakes to avoid
- Replacing the patient's functional goal with a presumed diagnosis.
- Promising insurance coverage based on the presence of a referral.
- Sending automated exercise instructions before clinical evaluation.
What it pairs with
Most teams don't run this form on its own. These are the forms and systems it sits next to.
What to do with the responses
The clinic should confirm scheduling and billing arrangements, flag relevant clinical history for the therapist and use the patient's activity goals to guide the evaluation interview.
Works in both layouts
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Privacy & compliance
This form collects health information. Keep access limited to the people who need it, turn on encrypted answers for the clinical questions, and set a retention window so records don't sit in the dashboard forever.
Frequently asked questions
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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