Physiotherapy Intake Form Template
A first physiotherapy appointment is mostly subjective examination, and most of it can be gathered before the patient arrives. This template collects the presenting complaint and body region, how and when it started, pain now, at its worst and at its best, what aggravates it and what eases it, the effect on work and sleep, imaging or surgery already done, a safety checklist, and — in the patient's own words — what they most want to be able to do again.
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Fields in this template
- Full Namerequired
- Date of Birth
- Email Addressrequired
- Phone Number
- Have you seen a physiotherapist before?required
No, this is my first time · Yes, for this same problem · Yes, but for something else · Yes, I'm currently seeing one elsewhere
- What are you coming in for?required
- Main Body Region Affectedrequired
Neck · Upper back or mid back · Lower back · Shoulder · Elbow or forearm · Wrist or hand · Hip or groin · Thigh or hamstring · Knee · Lower leg, calf or Achilles · Ankle or foot · Jaw · Chest or ribs · Pelvis or pelvic floor · More than one area · Not sure
- Which side?required
Left · Right · Both sides · Down the middle or not side-specific
- How long have you had this problem?required
Less than a week · 1 to 4 weeks · 1 to 3 months · 3 to 6 months · 6 to 12 months · 1 to 5 years · More than 5 years · It comes and goes and has done for years
- Date It Started, If You Know It
- How did it start?required
A specific injury, fall or accident · Gradually, with no obvious cause · After a change in training, sport or activity · After a change at work or a new task · After an operation · After an illness · During or after pregnancy · Not sure
- Tell us what happenedrequired
- Pain right nowrequired
0 — no pain · 1 · 2 · 3 · 4 · 5 · 6 · 7 · 8 · 9 · 10 — worst pain imaginable
- Pain at its worst in the past week
0 — no pain · 1 · 2 · 3 · 4 · 5 · 6 · 7 · 8 · 9 · 10 — worst pain imaginable
- Pain at its best in the past week
0 — no pain · 1 · 2 · 3 · 4 · 5 · 6 · 7 · 8 · 9 · 10 — worst pain imaginable
- What makes it worse?required
- What makes it better?
- What do you do for work?
- How is this affecting your work or daily activities?
- How is this affecting your sleep?required
Not at all · It takes me longer to get to sleep · It wakes me occasionally · It wakes me most nights · I am getting very little sleep because of it
- What else is it getting in the way of?
Walking · Driving · Standing · Sitting · Household tasks · Sport, training or exercise · Hobbies · Caring for children or family · Socialising · My mood · Nothing much yet
- What has already been done for this problem?
X-ray · MRI scan · CT scan · Ultrasound scan · Nerve conduction study · Blood tests · Surgery · Steroid or other injection · Physiotherapy · Osteopathy or chiropractic · Massage or soft tissue therapy · Acupuncture or dry needling · Prescription pain medication · A brace, boot, splint or support · Nothing yet
- Details of any imaging, surgery or treatment above
- Link to a Referral Letter or Report, If You Have One Online
- Relevant medical history
- Current medication
- Are you pregnant, or have you given birth in the last six months?
No · Yes — currently pregnant · Yes — in the last six months · Prefer not to say
- Safety checklist — have you had any of the following?required
Unexplained weight loss · Fever, chills or night sweats · Pain that wakes you every night and does not ease when you change position · Numbness or tingling around the groin, buttocks or inner thighs · A change in bladder or bowel control · Weakness in an arm or leg that is getting worse · A previous diagnosis of cancer · A significant fall, accident or blow in the last few weeks · Long-term steroid use · Recent unexplained dizziness, blackouts or visual changes · None of these
- Anything you ticked above that you want to explain
- What do you most want to be able to do again?required
- Access or communication needs for your appointment
- Before You Submitrequired
I understand this form is used to prepare for my appointment, that it is not a request for urgent or emergency care, and that nobody may read it before I am seen.
Who uses this template
About this template
A physiotherapy intake form is not a general patient registration form with a physiotherapy label on it. The subjective examination that opens a first musculoskeletal appointment is a specific sequence — what the problem is, where it is, how and when it started, what makes it worse, what makes it better, what it is stopping the person doing — and almost all of it can be gathered in advance. When it is, the appointment starts at the objective examination instead of at question one.
This template follows that sequence. Pain is recorded three times rather than once, because a patient at 2 out of 10 now and 9 out of 10 at worst has a very different problem from one sitting steadily at 6, and a single score cannot tell those apart. Aggravating and easing factors are asked as two separate questions rather than one combined box, because the answers point in different directions clinically. Onset is asked twice on purpose — a structured question for the pattern and a required free-text box for the mechanism, since how someone landed, lifted or twisted is usually the single most informative sentence on the whole form. The safety checklist near the end is written as a checklist with a plain instruction attached: it tells the patient which symptoms mean not waiting for the appointment, and it says in the field itself that ticking a box is not a diagnosis.
This is a template, not a clinical instrument. Have a qualified physiotherapist in your own jurisdiction review and adapt it before you use it with patients — the wording of the safety questions in particular should match the screening your service already uses and the scope you are registered to practise. formformform hosts every form in the EU and handles submissions under GDPR, and end-to-end encryption is available as an opt-in switch on your own copy of the form. Neither this template nor the platform makes any practice compliant with HIPAA, SOC 2, ISO 27001 or any other framework, and no form replaces a clinical assessment — providers are responsible for validating their own legal and regulatory requirements.
12 form ideas you can build with this template
Private MSK Physiotherapy Clinic Intake
Gather the full subjective examination before a first private appointment so the session opens with hands-on assessment rather than history taking.
Sports Injury Clinic Intake Form
Record the mechanism of injury, the training change that preceded it, and a return-to-sport goal in the athlete's own words.
Post-Surgical Rehabilitation Intake
Capture the operation, its date and what the patient was told, alongside current pain and function, before the first rehab session.
Back Pain Triage Support Form
Collect onset, aggravating factors and the safety checklist ahead of an appointment so the clinician knows which questions to open with.
Occupational Health Physiotherapy Referral Intake
Record the job, the tasks being avoided and any modified duties, so a workplace physiotherapy plan starts from the actual role.
Home Visit Physiotherapy Intake
Use the access and communication needs field to record stairs, parking and entry details alongside the clinical history before a domiciliary visit.
Hand Therapy Intake Form
Trim the body region dropdown to wrist, hand and elbow and keep the three pain scores for a specialist upper-limb caseload.
Pelvic Health Physiotherapy Intake
Keep the pregnancy and postnatal question, narrow the region list, and use the goal field to let patients describe outcomes in their own terms.
Running Injury Assessment Intake
Combine the onset question, aggravating factors and a distance-based functional goal for a running-specific physiotherapy service.
Multi-Disciplinary Clinic Physiotherapy Intake
Run this alongside the chiropractic and podiatry intakes in a clinic where a patient may be routed to any of the three.
Sports Club Physiotherapy Screening Intake
Collect a squad member's current complaint, pain range and training impact before an in-house physiotherapy slot.
Physiotherapy Waiting List Update Form
Re-send the same form to someone who has been waiting, so the pain scores and functional goal are current on the day they are finally seen.
What's included
How to create a physiotherapy intake form
- 1
Click "Use this template" to load the physiotherapy intake form into your free formformform account.
- 2
Have a qualified physiotherapist review the wording before you publish it — particularly the safety checklist, which should match the screening questions your own service uses.
- 3
Adjust the body region dropdown to your caseload — a hand therapy service or a pelvic health service will want a much shorter, more specific list.
- 4
Decide which fields your service genuinely requires. Date of birth, phone number and medication all ship optional with a note explaining when to switch them on.
- 5
Add conditional logic in the editor if you want follow-up questions to appear only for certain answers — for example post-surgical questions only when "After an operation" is selected. Templates cannot ship with branching, so this is a step you add after cloning.
- 6
Add an Upload field in the editor if you want patients to attach imaging reports or referral letters, then delete the text link field this template ships with.
- 7
Turn on end-to-end encryption for the form in your account settings before sharing it, if you want each answer sealed in the patient's browser before it is stored.
- 8
Share the link in your booking confirmation, and set an email notification so the form reaches the treating clinician before the appointment, not after.
Best practices for your physiotherapy intake form
the safety checklist especially should match your own service's screening protocol and your scope of practice.
Keep all three pain questions. The temptation is to cut to one score to shorten the form, but best-and-worst is where the useful information is, and only the current score is required so nobody is blocked by the other two.
Do not turn the safety checklist into a triage step. It flags which questions to ask first; it does not decide who is seen or how quickly. Keep the instruction telling patients to seek urgent care rather than wait, and make sure it sits above, not below, the checklist.
Ask for the mechanism in free text and leave it required. Structured onset options are useful for filtering, but the sentence describing what actually happened is what changes the assessment.
a specialist service gets better data from six options that match its own clinic codes.
Read the goal field before the appointment, not during it. It is the one field written entirely in the patient's language, and starting the session from it changes the tone of the whole appointment.
so switch it on before responses start, not after.
Validate your own compliance obligations separately. Using this template does not make a practice HIPAA compliant and does not represent any certification; check what applies to you with your own advisers.
Frequently asked questions
Is this physiotherapy intake form template free?
Yes. You can use it, customise it and collect unlimited submissions at no cost, with no per-submission fees.
Can I use this form as it is?
Not without review. It is written as a well-structured starting point, not as a validated clinical instrument — have a qualified physiotherapist in your jurisdiction check the wording, especially the safety checklist, against the screening your service already uses.
Why does it ask for pain three times?
Because one number hides the range. Someone at 2 out of 10 right now but 9 at their worst has a different problem from someone sitting steadily at 6, and only asking for the current score makes the two look identical. Only the current score is required.
Is the safety checklist a red-flag screening tool?
No. It is a checklist that tells the physiotherapist which questions to ask first, and it says so in the field itself. It does not diagnose, triage or decide urgency, and it carries a plain instruction that certain symptoms mean seeking urgent medical care rather than waiting for the appointment.
How is this different from the chiropractic intake template?
The chiropractic template records one pain score, one onset question and a symptom checklist, then moves on to insurance coverage. This one asks for three pain scores, separates aggravating from easing factors, records the effect on work and sleep, lists imaging and surgery already done, and ends on a required functional goal in the patient's own words.
Can patients attach their scan reports?
This template collects the details as text rather than as a file, because templates cannot ship with an upload field. Add an Upload field to your own copy in the form editor if you want attachments — formformform supports uploads on any form at up to 2 MB per file, and they stay encrypted on end-to-end encrypted forms.
Is this form HIPAA compliant?
No form makes a practice HIPAA compliant on its own. formformform hosts in the EU, handles submissions under GDPR, and offers optional end-to-end encryption you can enable per form. HIPAA compliance depends on your full data-handling workflow — check your obligations with your own compliance advisers.
Can I add conditional questions for post-surgical patients?
Yes, in the editor after you clone it. Templates cannot ship with branching logic, so this form is flat by design — add the rules yourself so post-operative questions appear only when a patient says the problem started after an operation.
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