Physical Therapy Intake Form
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Physical Therapy Intake Form
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The Physical Therapy Intake Form is designed for PT clinics, sports medicine practices, and rehabilitation centers. It captures the specialized information physical therapists need to develop an effective treatment plan: detailed injury or condition description, mechanism of injury, onset date, pain assessment using the Visual Analog Scale (VAS), functional limitations, and previous treatments.
The form includes body map pain location selection, allowing patients to precisely indicate where they experience symptoms. Functional limitation checklists cover activities of daily living, work-related tasks, and recreational activities, giving the therapist a clear picture of the patient's current functional status.
Referring physician information and insurance authorization details are captured upfront, streamlining the administrative process. Treatment goals are set collaboratively with the patient during intake, establishing measurable outcomes from day one. This template is also suitable for occupational therapy, speech therapy, and cardiac rehabilitation programs with minor customization.
What's included
- Injury description and mechanism of onset
- VAS pain scale and body map selection
- Functional limitations checklist
- Previous treatment and therapy history
- Treatment goals and expectations
- Referring physician and insurance authorization
- Insurance information collection with carrier and policy details
Who uses this template
- Physical therapy clinics and rehab centers
- Sports medicine practices
- Occupational therapy offices
- Post-surgical rehabilitation programs
All form fields
12 fields across 2 pages. Customize any field after signing up.
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