Patient Information – This first section usually collects basic patient info, such as name, age, gender, contact information, and emergency contacts.

Insurance Information – If the therapy is covered under an insurance policy, the patient will need to provide primary insurance provider information.

Current Condition – The patient will be asked to describe their reason for seeking physical therapy, including their symptoms, pain levels, and functional limitations related to the condition or injury.

Medical History – The form usually requires the patient to disclose current or past illnesses, surgeries, and conditions, as well as any medications they are taking.

Health Habits & Lifestyle – It’s common for the intake form to include questions related to the patient’s health, hobbies, exercise, and negative lifestyle factors like cigarettes and alcohol.

Consent and Authorization – An intake form will often include language that has the patient consenting to receive treatment and acknowledge that they’ve provided complete and accurate information.

Signature and Date – The patient’s signature and date will validate the authenticity of the information provided and demonstrate they understand and consent to treatment.