Template library · Intake forms
Physical Therapy Intake template
Please complete before your first physical therapy visit.
- 18 fields across 3 sections
- Included with MyWellOps
- Edit it, or save your own version
What’s in it
- DateDate
- PractitionerText
Contact & Insurance
- Full nameText
- Date of birthDate
- Phone numberText
- EmailText
- Referring physician (if any)Text
- Insurance providerText
Injury/Condition Details
- Reason for referral / primary complaintText
- When did symptoms begin?Date
- Current pain levelText
- OtherText
- Prior surgeries related to this conditionText
- Affected areas (check all that apply):
- Neck
- Shoulder
- Back
- Hip
- Knee
- Ankle/foot
Function & Goals
- Daily activities affected by this conditionText
- Have you had physical therapy before?Choice
- Goals for physical therapyText
- Client signatureSignature
- Date signed (client)Date
When to use it
Send an intake form when a new client books, so their history, contact details and reasons for coming are in front of you before the first appointment rather than taken down during it.
How it works in MyWellOps
- Choose it from Documents and adjust the questions to your practice.
- Send it to the client, who completes it in their client portal.
- Their answers are kept on the client’s record, ready for the first session.
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