PT Intake Form Template

First PT visits go faster when the chart already has the story. This PT intake form template collects contact details, the injury picture, pain levels, and goals before the patient walks in.

Great for

• Outpatient PT clinics onboarding new patients
• A pre-visit link sent after booking the eval
• Sports medicine practices gathering injury history on a phone

Focus on the problem that brought them in: where it hurts, when it started, and what they want to return to. Leave full medical history grids for your EHR if you already have one.

Send the form with the appointment confirmation so answers are ready before the eval. Export CSV when you need a simple archive outside the clinic system.

Questions in this template

1. Patient full name *
   Name
2. Email *
   Email
3. Phone number *
   Phone
4. Date of birth *
   Date
5. Referring provider (if any)
   Short text
6. Primary area of pain or injury *
   Short text
7. How did the injury or symptoms start? *
   Long text
8. When did symptoms start? *
   Date
9. Average pain level right now *
   Rating scale
10. What makes symptoms better or worse? *
    Long text
11. What activities are hard right now? *
    Long text
12. Have you had PT or surgery for this issue before? *
    Yes or no
13. Medications or allergies we should know about *
    Long text
14. What do you want to get back to? *
    Long text
15. Signature (type your full name) *
    Short text