Patient Intake  ·  Popular

Streamline Your Physical Therapy Patient Intake

Gather patient demographics, insurance information, and physician referral details efficiently before every physical therapy visit.

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Neo theme
formbuilder.ai/f/physical-therapy-patient-intake-form
Physical Therapy Patient Intake Form
Patient Full Name
· · ·
Date of Birth
· · ·
Sex
Submit

The Physical Therapy Patient Intake Form is designed to help PT clinics and rehabilitation centers collect essential patient information before the first appointment. It covers personal details, emergency contacts, insurance coverage, and physician referral data all in one organized form.

This template is ideal for physical therapists, sports rehab facilities, and outpatient therapy practices looking to reduce paperwork and streamline the check-in process. Patients can complete the form online in advance, saving valuable chair time and improving the overall care experience.

By digitizing your intake process, you minimize manual data entry errors, ensure HIPAA-aligned data collection, and keep patient records complete from day one. Customize the form to match your clinic's branding and specific clinical requirements with ease.

4 Pages
29 Questions
~10min To complete
Free No credit card needed
Field types Full Name ×4 Short Text ×4 Long Text ×4 Date ×3 Phone ×3 Single Choice ×2 Multiple Choice ×2 Email Address File Upload Yes / No Star Rating termsandconditions Signature

Questions in this template

Free template

The exact questions included — customize any of them to fit your needs.

Page 1 Personal Information 9 questions
Patient Information
1 Patient Full Name * Full Name
2 Date of Birth * Date
3 Sex * Single Choice
4 Email Address * Email
5 Phone Number * Phone
6 Home Address * Address
Emergency Contact
7 Emergency Contact Name * Full Name
8 Emergency Contact Phone Number * Phone
9 Relationship to Patient * Short Text
Page 2 Insurance & Referral Details 7 questions
Insurance Information
1 Insurance Provider * Short Text
2 Policy / Member ID Number * Short Text
3 Group Number Short Text
4 Primary Policyholder Name * Full Name
Physician Referral
5 Referring Physician Name Full Name
6 Referring Physician Phone Phone
7 Upload Referral or Prescription (if applicable) File Upload
Page 3 Medical History & Current Condition 10 questions
Medical History
1 Do you have any of the following conditions? * Multiple Choice
2 Please list any previous surgeries or hospitalizations Long Text
3 Current Medications (include dosage if known) Long Text
4 Do you have any known allergies to medications? * Yes / No
5 If yes, please list allergies Long Text
Current Condition
6 Describe your primary reason for seeking physical therapy * Long Text
7 When did your symptoms begin? * Date
8 Current Pain Level (1 = minimal, 5 = severe) * Star Rating
9 How did your condition occur? * Single Choice
10 Which daily activities are affected by your condition? * Multiple Choice
Page 4 Consent & Signature 3 questions
Consent & Authorization
By signing below, I certify that the information provided is accurate and complete to the best of my knowledge. I authorize the physical therapy team to evaluate and treat my condition. I understand that I may withdraw consent at any time.
1 I have read and agree to the Patient Consent and Privacy Policy * termsandconditions
2 Patient Signature * Signature
3 Date of Signature * Date

How to use this template

Click "Use This Template Free" to open it in the FormBuilder editor. From there you can add, remove, or reorder fields with drag-and-drop, switch themes for instant restyling, add your logo, configure email notifications, and set your success message. When ready, publish with a unique link and start collecting responses immediately.

  • Ready-to-use structure — pre-configured fields out of the box
  • Applied "Neo" theme — fonts, colors, and layout already set
  • Mobile-responsive — works on every device without extra configuration
  • Fully editable with drag-and-drop — change anything in seconds
  • Free to use on any plan, no credit card required

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Free to use. Open in the editor, customize, and publish in minutes.

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Category Intake & Onboarding
Subcategory Patient Intake
Theme Neo
Badge Popular
Price Free
Coding required None
Tags
Healthcare Fitness Patient

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