A physical therapy intake form is a form given to a new patient to fill out before their first physical therapy session. The document consists of a series of questions related to the patient’s current condition, symptoms, and medical history. The intake form is essential to helping professional therapists assess the issue and develop a treatment plan.

Notice of Privacy Practices

In accordance with the Health Insurance Portability and Accountability Act (HIPAA), physical therapists must give patients a Notice of Privacy Practices before beginning treatment.

What to Include in an Intake Form
Initial Evaluation
Related Forms (3)

What to Include in an Intake Form

Patient Information – This first section usually collects basic patient info, such as their 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 will usually require 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 – Patients are often required to give consent to receive treatment and acknowledge that they’ve provided complete and accurate information.
Signature and Date – The patient will need to sign and date the intake form to validate their consent and provide the physical therapist with certain liability protection.

Initial Evaluation

At the first meeting between a patient and a physical therapist, the therapist will review the patient’s intake form, assess their condition, establish treatment goals, and develop an individualized treatment plan. The process will involve more steps if the therapist has a pediatric practice. While not all therapists follow the same procedure, a typical initial evaluation will go something like this:

Introduction – The physical therapist introduces themselves and provides a brief overview of their process.
Assessment – The therapist looks over the patient’s intake form and clarifies information through questions, physical evaluation, and observation.
Discussion of symptoms and goals – The patient will be asked about their symptoms, pain levels, and treatment goals.
Treatment plan – Based on the assessment, the therapist will propose a treatment plan which will usually involve exercises, stretches, and manual therapy techniques. The therapist will coach the patient on how to perform the required movements and exercises.
Booking future sessions – The therapist will propose a schedule for future sessions along with the complementary work that the patient must complete between appointments. Depending on the patient’s issue, the therapist may provide an estimate of when their symptoms will be alleviated.