Physiotherapy Intake Form
Physio intake covering the injury or pain, how it started, what makes it worse, previous treatment, the activity goals, and consent to assess and treat.
A ready-to-use healthcare & clinical form for small teams who need a reliable intake process: 17 questions, 2 pages, 3 conditional rules.
- Questions
- 17
- Pages
- 2
- Layouts
- classic · card
- Time to complete
- ≈ 6 min
- Conditional rules
- 3
Searches this template answers
- physiotherapy intake form
- physical therapy intake form template
- physio new patient form
- rehab intake form online
- musculoskeletal intake form
- physiotherapy assessment form
Also filed under
Live preview and test console
This is the real form. Answer it to test the 1 conditional rule — nothing is sent or stored.
Page 1 of 2 — The problem
Every question on this page is currently visible.
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
Physiotherapy 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 17 questions across 2 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.
- 12 questions are required, so submissions arrive complete instead of needing a follow-up email.
- It captures a phone number for urgent follow-up.
- It accepts a document or photo upload as evidence.
- It pins the request to a specific date.
- It allows multiple selections without free text.
- Conditional logic hides 3 questions until they are relevant — shorter forms convert better than long ones.
- Splitting the form across 2 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 Physiotherapy 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.
- 4Check the upload limits on the file question so respondents can attach what you actually need.
- 5Publish 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.
- 6Watch 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 “How did it start?” is Sudden injury, “What were you doing when it happened?” becomes mandatory before the form can be sent.
- Features conditional validation: if “Have you had treatment for this before?” is Yes, “What treatment, and did it help?” becomes mandatory before the form can be sent.
- Features advanced show logic: if “Do you have any imaging or letters?” is Yes, the form dynamically exposes “Upload imaging report or referral letter”. Otherwise that question never appears.
- All 3 rules are editable in the Logic tab, and the built-in checker warns about rules that contradict each other.
About this template
Physiotherapy assessments run better when the story arrives first. This intake collects the history a physio would otherwise spend the first fifteen minutes writing down: where the problem is, when and how it started, whether it came on suddenly or gradually, what makes it better or worse, and how it behaves across a day. It asks about previous episodes and previous treatment, because a problem that has been treated three times is a different conversation from a first presentation. Work and activity questions cover what the patient actually needs to get back to — lifting at work, a sport, sleeping through the night — which is what turns a plan into something a patient will follow. There is space for imaging or letters to be uploaded, so a report is not described from memory. The final page records consent to physical assessment and hands-on treatment, and asks about anything the physio should know before touching the area. No question here interprets the problem; the assessment in the room does that.
What this form asks
Every question is editable — rename it, make it optional, or delete it entirely.
Page 1 — The problem
- Full namerequired
- Date of birthrequired
- Contact numberrequired
- Where is the problem?required
- When did it start?required
- How did it start?required
- What were you doing when it happened?
- What makes it worse, and what eases it?required
- How is it across a day?required
Page 2 — History and goals
- Have you had treatment for this before?required
- What treatment, and did it help?
- Do you have any imaging or letters?required
- Upload imaging report or referral letter
- Your work and what it involves physically
- What do you want to be able to do again?required
- Anything the physio should know before assessing you
- Consentrequired
17 questions in total.
Example of a completed physiotherapy intake form
A sample intake showing how a patient describes an injury and their goals before a first physio session.
- Full name
- Chloe Bennett
- Date of birth
- 23/10/1996
- Where is the problem?
- Right shoulder
- When did it start?
- 6 weeks ago
- How did it start?
- Came on gradually
- What makes it worse, and what eases it?
- Worse reaching overhead, eased by rest and heat
- Have you had treatment for this before?
- No
- What do you want to be able to do again?
- Swim freestyle without pain
Sample data — no real people, addresses or records are shown.
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 “How did it start?”
- Makes answers required
If “How did it start?” is Sudden injury, “What were you doing when it happened?” becomes required before the form can be submitted.
Driven by “Have you had treatment for this before?”
- Makes answers required
If “Have you had treatment for this before?” is Yes, “What treatment, and did it help?” becomes required before the form can be submitted.
Driven by “Do you have any imaging or letters?”
- Reveals questions
If “Do you have any imaging or letters?” is Yes, the form reveals “Upload imaging report or referral letter”.
Set it up step by step
- 1
Ask for goals in the patient's words
"Carry my toddler upstairs" gives a physio a target that a pain score never will, so keep that field open text.
- 2
Collect uploads before the first session
An imaging report read beforehand saves assessment time and avoids repeating tests the patient has already had.
- 3
Keep consent on the second page
Consent to hands-on treatment belongs after the patient has described the problem, not as a gate before they start.
- 4
Reuse it for review appointments
Sending the same form again at week six shows change in the patient's own wording rather than in your notes only.
Mistakes to avoid
- Replacing the story with a pain scale, which records intensity and loses the pattern.
- Never asking about previous treatment, then repeating something that already failed.
- Burying consent in a paragraph of terms rather than making it a distinct question.
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
Read the intake before the session, plan the assessment around the stated goal, and agree a review point where the same questions can be asked again.
Works in both layouts
Forms that overlap this one
These pages cover the same subject ground as the physiotherapy intake form, matched on the words people actually search for.
Chiropractic Intake Form
clinicclinicalconsenthealthhistory
Dermatology Patient Intake Form
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Pediatric Intake Form
clinicclinicalconsenthealthhistory
Pain Assessment Questionnaire
assessmentclinicclinicalcoordinatorcovering
Quick Patient Registration
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Eye Exam Intake Form
clinicclinicalhealthhistoryintake
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
How is this different from the Chiropractic Intake Form?
The clinical framing differs: this one focuses on activity limitation, aggravating movements and rehabilitation goals, while the chiropractic version asks more about spinal history and prior manual treatment.
Does it work for self-referrals?
Yes. Referral letters are optional and uploaded only when they exist, so a patient booking themselves in supplies the same history.
Should we ask for a pain score?
Add one if your outcome reporting needs it, but keep the aggravating and easing questions, because those are what shape the first session.
Can it be used before a video assessment?
Yes, and it matters more there — a remote session cannot afford fifteen minutes of history taking before anything is observed.
Is the Physiotherapy Intake Form template free to use?
Yes. You can preview and test Physiotherapy 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 Physiotherapy Intake Form template ask for?
It asks 17 questions across 2 pages, 12 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 Physiotherapy 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 “How did it start?” is Sudden injury, “What were you doing when it happened?” becomes mandatory before the form can be sent. Features conditional validation: if “Have you had treatment for this before?” is Yes, “What treatment, and did it help?” becomes mandatory before the form can be sent. Features advanced show logic: if “Do you have any imaging or letters?” is Yes, the form dynamically exposes “Upload imaging report or referral letter”. Otherwise that question never appears. All rules are editable in the Logic tab.
Where do responses to the Physiotherapy 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 Physiotherapy 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.
Can respondents upload files?
Yes. This template includes a file upload question, so respondents can attach documents or photos with their answers. You can adjust the accepted file types and size limits on that question.
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