PT intake form

A PT intake form is the questionnaire a new physical therapy patient completes before the first appointment. It records demographics, medical history, pain, functional limitations, and HIPAA authorization, so the therapist starts the evaluation with a full baseline.

This free template gives you that structure ready-made, from baseline range of motion and strength screening through to return-to-activity criteria. Download the PDF, adjust the fields to your practice, and start collecting complete, comparable patient data at intake.

Key takeaways

A PT intake form collects demographics, medical history, the chief complaint, pain assessment, insurance details, and HIPAA authorization before a patient’s first physical therapy appointment.

Every physical therapy intake form should include medical and surgical history, current medications, functional limitations, pain scales, the referral source, and e-signature consent.

Digital PT intake forms, sent through an online portal or practice management software, cut paperwork, auto-populate patient records, and improve compliance compared with paper.

Practice management software like Pabau sends HIPAA-compliant intake forms to patients before appointments and files the answers in the clinical record, cutting manual data entry.

What is a PT intake form?

A PT intake form documents a new patient’s baseline health status, functional ability, and clinical presentation before treatment begins. Assessment, treatment planning, and every later progress note build on it.

The form captures critical information that informs clinical decision-making: Past injuries, surgeries, medications, pain patterns, movement limitations, and the reason for the visit. Stored in a physical therapy EMR, the completed form becomes a permanent record that supports clinical continuity, documentation standards, and billing accuracy.

A well-designed intake form also covers legal and regulatory obligations: It documents informed consent and captures HIPAA authorization. It also shows that the clinician screened for red flags and contraindications before treatment began.

What to include on the form

Every physical therapy intake form should capture these core sections:

• Patient demographics and contact information: Name, date of birth, address, phone, email, emergency contact, insurance details
• Medical and surgical history: Past diagnoses, prior surgeries, allergies, current medications, functional status baseline
• Chief complaint and pain assessment: Reason for visit, location and severity of pain (numeric scale), onset and duration, functional limitations
• Insurance and referral information: Primary care provider, referral source, authorization requirements, workers’ compensation status
• Informed consent and HIPAA authorization: Acknowledgment of risks, treatment authorization, privacy notice, e-signature

Each section feeds a different decision later in the episode of care. The map below shows where your team uses the answers.

Patient demographics and contact information

Collect name, date of birth, address, phone number, email, and emergency contact. Add the insurance carrier, policy number, and group number, then verify insurance eligibility at intake so billing problems surface before the first visit.

Medical history and current medications

Document past diagnoses, surgeries (especially spine, joint, or trauma), fractures, and any ongoing medical conditions. List all current medications with dosages. This informs clinical safety: Certain drugs affect healing or pain perception, and past surgical hardware may limit range of motion or imaging options.

Chief complaint and pain assessment

Record the primary reason for the visit in the patient’s words. Then score pain on a 0–10 numeric pain rating scale and describe its character (sharp, dull, burning, aching). Document onset, aggravating factors, and functional limitations: “Cannot walk > 10 minutes without sharp knee pain.” This baseline enables comparison at re-assessment.

Insurance information and referral details

Capture the referring physician’s name and credentials, authorization requirements (many insurers require pre-approval), and workers’ compensation status if applicable. Documenting the referral source is part of physical therapy compliance in many jurisdictions.

Consent and HIPAA authorization

Include a statement confirming the patient has been informed of treatment risks and benefits and consents to proceed. Under HIPAA regulations, you must provide the Notice of Privacy Practices and obtain written authorization to use and disclose the patient’s health information. An e-signature pad captures proof of consent and reduces paper burden.

How to roll out the template in five steps

Follow these steps to put the template to work in your PT practice:

1. Download the PDF. The template is available above. Open it in Adobe Acrobat or another PDF editor and review the structure and field names. Check that they match your practice’s workflow and assessment protocols.
2. Customize fields for your practice. Edit section titles and add or remove questions (e.g., if you specialize in sports injury or post-surgical rehab). Add your practice name, logo, and contact information at the top. Tailor the medical history section to your most common patient presentations.
3. Test with a pilot patient. Print or email the form to a trusted existing patient and ask for feedback on clarity and length. Does it take about 10–15 minutes to complete? Are any questions unclear? Revise based on feedback before rolling out practice-wide.
4. Set up a collection process. Choose how patients complete the form: On paper before the visit, by email or patient portal, or on an iPad in the waiting room. Collecting before the visit captures the data upfront, even if the patient no-shows. Digital collection also cuts data entry, because answers auto-populate the patient record.
5. Train staff and clinicians. Make sure your front desk team explains the form’s purpose to patients and answers questions. Clinicians should review intake data before the session and flag red flags such as recent surgery, uncontrolled pain, or signs of serious pathology.

Paper vs. digital intake forms: Which is better for your practice?

Paper intake forms are low-cost and need no technology. But they create manual data entry and keep patients filling in forms at the appointment, which lengthens wait times. They also carry a higher risk of lost or illegible responses.

Digital forms address all three: Patients complete them on their own time before the appointment, and responses are immediately available in your practice software. Patient compliance with data collection also improves when that friction is removed.

For most PT practices, digital is the practical choice: Patients start intake before arrival, and your clinician reviews the data ahead of the session. Your front desk also spends far less time on paperwork.

Turning intake answers into a usable baseline

The intake form sets the baseline that every later note is measured against. A complete one lets clinicians show progress at re-assessment and supports APTA documentation standards.

Paper or digital, the job is the same: Collect complete baseline data before treatment begins. That baseline is what lets clinicians make informed decisions and track progress over time.

The two formats differ in where the answers end up. Paper answers wait on the page until someone types them into the chart. Digital answers flow straight into assessment notes, treatment plans, and billing records.

How Pabau automates physical therapy intake forms

On paper, intake means a clipboard at check-in and a staff member retyping answers into the chart afterward. Practice management software like Pabau replaces that with patient intake software that sends HIPAA-compliant forms to patients before their appointments.

Patients complete the form on any device, and responses auto-populate into the patient record, so clinicians see the data before the session starts. Pabau sends the form automatically after booking confirmation, tracks completion, and reminds patients who haven’t finished. It also flags missing fields so your team can follow up before the visit.

Every response is encrypted and stored with a complete audit trail to support HIPAA documentation requirements. During the appointment, Pabau Scribe, our AI medical scribe, turns clinicians’ dictated findings into structured notes. Those notes sit in the same patient record as the intake answers, so nobody re-enters baseline information.

Send intake forms before the first visit

Pabau sends HIPAA-compliant intake forms after booking, reminds patients who haven’t finished, and files every answer in the patient record. Your therapists start the evaluation with the history already in front of them.

Book a demo

Conclusion

Start with the template as it stands, then trim or add questions until a new patient can finish it in 10–15 minutes. A shorter form that patients complete gives your clinician more to work with than a long one they abandon.

The bigger decision is where the answers go. If your front desk retypes intake data into the chart, move collection online before the first visit. The baseline then reaches the clinician without transcription, and red flags get reviewed before the patient walks in.

Book a demo to see how Pabau automates intake for PT practices, from booking confirmation to the first evaluation note.

Continue your research

Need a consistent pain score at intake? Numeric pain rating scale gives patients a standard 0–10 scale to rate pain at every visit.

Want patients to show where it hurts? Body pain chart lets patients mark the location and type of their pain on a body diagram.

Tracking lower-limb function? Lower Extremity Functional Scale template scores how hip, knee, ankle, and foot problems affect daily activity.

Treating low back pain? Oswestry Disability Index template measures how back pain limits everyday tasks.

Getting paid for the evaluation? Physical therapy billing explains how PT practices code and submit claims.

Frequently asked questions