Intake Forms for Physical Therapists: Functional Assessment, Pain Mapping, and Treatment Goals

By Daniel Akselrod · July 2026

Physical therapy intake is not the same as general medical intake. A physician needs to know what is wrong. A physical therapist needs to know what the patient cannot do, what they want to be able to do, and what is standing in the way. That distinction should shape every field on your intake form. If you are still using a generic health history questionnaire borrowed from a primary care office, you are collecting the wrong information and missing the data that actually drives your plan of care.

A well-designed PT intake form does three things before the patient ever gets on a treatment table: it captures the referral and authorization details that keep you compliant and paid, it establishes a functional baseline you can measure progress against, and it documents the patient’s own goals so your treatment plan reflects what matters to them — not just what the diagnosis code says.

Referral and Prescription Information

In most states, physical therapy requires a physician referral for insurance reimbursement. Even in direct-access states where patients can self-refer, many insurance plans still require a referral or prior authorization before they will cover visits. Your intake form needs to capture this upfront, because a missing referral discovered three visits in means three visits you may not get paid for.

The referral section should include the referring physician’s name, practice, phone number, and fax number. Capture the primary diagnosis and ICD-10 code exactly as written on the referral — mismatched codes between the referral and your billing are a leading cause of claim denials. Document the number of authorized visits, because PT benefits almost always have visit limits. Twenty visits per year is common for commercial plans, and Medicare has a therapy cap with an exceptions process that requires additional documentation. Record any precautions or contraindications noted by the referring physician: weight-bearing restrictions, movement limitations, cardiac precautions, or post-surgical protocols with specific timelines. These are not suggestions — they are the guardrails your treatment plan must stay within.

Medical and Surgical History with PT-Specific Focus

Every healthcare provider collects medical history. What makes PT intake different is the focus. You do not need an exhaustive list of every medication the patient has ever taken. You need to know about the conditions and surgeries that directly affect how this person moves, tolerates exercise, and responds to manual therapy.

Joint replacements are at the top of the list. A patient with a total hip replacement has specific movement precautions — no flexion past 90 degrees, no internal rotation, no adduction past midline — and those precautions have timelines that vary by surgical approach. Anterior approach precautions differ from posterior approach. Your intake needs to capture not just that the replacement happened, but when, which joint, and which approach. Spinal surgeries are similarly critical: fusion levels and hardware placement dictate what mobilization techniques are safe. A patient fused at L4-L5 needs a fundamentally different treatment approach than one fused at C5-C6.

Cardiac history matters more than many PTs realize in outpatient settings. A patient with a history of congestive heart failure or recent cardiac event has exercise tolerance limits and vital sign parameters that must be monitored during treatment. Fall history is another area that deserves its own section rather than a single checkbox. For older adults especially, you need frequency of falls, circumstances (time of day, activity, location), injuries sustained, and whether the patient has developed a fear of falling — which itself affects gait and balance outcomes.

Functional Assessment Baseline

This is where a PT intake form earns its value. The functional assessment baseline is what separates a useful intake from a filing obligation. You are documenting, in the patient’s own words and your clinical observation, what this person cannot do right now. This becomes the yardstick for every progress note and the evidence for every reauthorization request.

Structure this section around activities of daily living and functional limitations. Can the patient lift their arm above their shoulder? Walk more than one block? Sit for more than 20 minutes without pain? Get in and out of a car? Climb stairs? Carry groceries? These are not abstract clinical measures — they are the things the patient cares about, and they are the things insurance companies want to see improving when you request additional visits.

Include transfer status (bed mobility, sit-to-stand, chair-to-toilet), gait status (assistive device use, distance tolerance, surface limitations), and work-related functional capacity if this is a workers’ compensation case. Document what the patient can do independently, what requires assistance, and what they cannot do at all. This three-tier framework — independent, assisted, unable — gives you a clean baseline for discharge planning.

Pain Assessment and Body Mapping

Pain is subjective, but your documentation of it should not be vague. A good PT intake form captures pain with enough specificity to inform treatment selection and track changes over time. Location is first — and a body diagram where the patient can mark pain areas is worth more than a text field asking them to describe it. Multiple pain sites are common, and each may have a different quality and pattern.

For each pain site, capture intensity on a 0–10 numeric rating scale at rest and with activity. Document pain quality using standard descriptors: sharp, dull, burning, aching, tingling, throbbing, stabbing. These words are not interchangeable — burning and tingling suggest neuropathic pain, which responds to different interventions than mechanical aching. Record aggravating factors (what makes it worse) and alleviating factors (what makes it better). Capture the pattern: is this constant or intermittent? Worse in the morning with stiffness or worse at end of day with fatigue? And document night pain specifically, because night pain that wakes the patient from sleep is a red flag for serious pathology — infection, tumor, fracture — that warrants further medical workup before proceeding with PT.

Patient Goals and Treatment Expectations

This is the section most generic intake forms miss entirely, and it may be the most important one on the page. Patient-stated goals drive the plan of care. They determine which interventions you prioritize, what functional milestones you set, and when the patient is ready for discharge. A 17-year-old soccer player recovering from an ACL reconstruction has very different goals than a 72-year-old with the same surgery. The teenager wants to return to competitive sport. The older adult wants to walk the dog without their knee giving out.

Give patients space to state their goals in their own language. “Pick up my grandchildren.” “Walk to the mailbox without stopping.” “Get back to my construction job.” “Sleep through the night without pain.” These patient-centered goals become your discharge criteria and the narrative thread of your documentation. When an insurance reviewer reads your notes, a clear line from “patient could not walk more than 50 feet at evaluation” to “patient now walks 500 feet independently and reports ability to complete grocery shopping” is the strongest case for medical necessity you can make.

Insurance Verification Specifics

Physical therapy insurance verification is its own discipline, and your intake form should capture the information your billing staff needs to verify benefits before or at the first visit. PT benefits often sit in a different section of the plan than medical benefits, with separate deductibles, copays, and visit limits. A patient’s medical plan may have a $30 copay, but their PT benefit has a $50 copay per visit — and they need to know that before they commit to a twice-weekly treatment plan.

Capture the insurance carrier, plan type (HMO, PPO, POS, Medicare, Medicare Advantage, Medicaid, workers’ compensation), group number, member ID, and the phone number on the back of the card for benefit verification. Document the annual visit limit — typically 20 to 60 visits for commercial plans — and how many have already been used if the patient has seen another PT provider this year. Note the deductible amount and how much has been met. Flag whether prior authorization is required and, if so, whether it has been obtained and how many visits are authorized. For Medicare patients, document awareness of the therapy cap and the exceptions process, which requires additional documentation demonstrating medical necessity for visits beyond the cap.

All of this information should be on your intake form, verified before or during the first visit, and communicated to the patient. Financial surprises are the fastest way to lose a patient to attrition, and in PT, patient attrition means incomplete treatment and worse outcomes.

If you are building or upgrading your physical therapy intake process, our Physical Therapy intake form set is designed with every section described above. It is a fillable PDF — no software subscription, no cloud dependency, no monthly fee. Download it, open it in any PDF reader, and start using it with your next patient. For practices that serve multiple healthcare disciplines, our Healthcare Bundle covers the full range of clinical specialties.