By the Templateez Team · Licensed Attorney · June 2026

Intake Forms for Physical Therapy and Rehabilitation: Clinical Assessment, Insurance Authorization, and Treatment Goals

Physical therapy is one of the few healthcare specialties where the intake form is not just an administrative necessity — it is the foundation of a clinical argument. Every field on a PT intake should connect to a measurable outcome, because those outcomes are what justify continued treatment to the insurance company that is deciding whether to authorize the next ten visits. A vague intake produces a vague treatment plan, and a vague treatment plan produces a denial letter.

The challenge is that PT intake has to serve multiple audiences simultaneously. The treating therapist needs clinical detail — pain location, functional limitations, surgical history, precautions. The front desk needs insurance verification and authorization numbers. The billing department needs ICD-10 codes and visit limits. And the patient needs to feel heard about the goals that actually matter to them: picking up a grandchild, returning to a sport, getting through a workday without pain. A well-designed physical therapy intake form captures all of this in a structured format that makes the first evaluation session productive instead of a forty-five-minute paperwork exercise.

Referral and physician information

Most PT patients arrive with a referral. In many states, direct access allows patients to see a physical therapist without a physician referral, but insurance reimbursement almost always requires one. The referral section of intake needs to capture enough information to satisfy both clinical and billing requirements:

• Referring physician — name, practice, phone number, and fax. Fax is not optional in healthcare — most physician offices still communicate treatment updates and progress reports by fax, and your intake should capture the number that ensures those documents reach the right desk.
• Diagnosis and ICD-10 code — the referring physician typically provides a diagnosis on the prescription. Your intake should capture both the narrative diagnosis (“right rotator cuff tear, post-surgical”) and the ICD-10 code (M75.111). If the referral does not include a code, your intake flags that the front desk needs to obtain it before billing can proceed.
• Prescription for therapy — what the physician specifically ordered. “Physical therapy 2–3x/week for 6 weeks” is different from “PT evaluation and treat.” The prescription language affects your plan of care and how many visits you can justify in your initial authorization request.
• Number of authorized visits — if pre-authorization has already been obtained, the authorized visit count needs to be documented at intake so the treating therapist knows the treatment window from the first session.
• Referral expiration date — referrals do not last forever. A referral that expires in thirty days and has not yet been used creates urgency. A referral expiring in six months provides flexibility. Either way, the date belongs on the intake form, not in someone’s memory.
• Primary care physician — if different from the referring physician, the PCP’s information should also be captured for coordination of care, especially when the patient has comorbidities that affect treatment.

Medical history for physical therapy

PT medical history is not a general health questionnaire. It is specifically oriented toward conditions that affect how a therapist can safely and effectively treat the patient. A form that asks “do you have any medical conditions?” with a blank line is not useful. The intake should screen for specific categories that change clinical decision-making:

• Surgical history — especially recent surgeries driving the referral. A patient six weeks post-ACL reconstruction has specific weight-bearing restrictions, range-of-motion limits, and tissue-healing timelines that dictate every exercise in their plan. Capture the surgery type, date, surgeon name, and any post-operative restrictions still in effect.
• Chronic conditions — diabetes (affects wound healing and sensation), cardiovascular disease (affects exercise tolerance and vital sign monitoring), osteoporosis (affects loading and manual therapy intensity), rheumatoid arthritis (affects joint handling), and neurological conditions (affects balance, coordination, and motor learning). Each of these changes the treatment approach, and the therapist needs to know about them before the patient is on the treatment table.
• Medications — blood thinners (bruising risk with manual therapy), muscle relaxants (altered muscle response during exercise), opioids (altered pain perception that can mask overexertion), corticosteroids (tissue fragility), and cardiac medications (heart rate response during exercise will not follow normal patterns). The medication list is not administrative paperwork — it is a clinical safety tool.
• Fall history — number of falls in the past twelve months, circumstances, injuries sustained. Fall history is both a clinical indicator and an insurance justification data point. A patient with three falls in six months has a documented need for balance training that is easier to authorize than a patient with no fall history requesting the same intervention.
• Cardiac precautions — pacemaker, stent, bypass history, exercise restrictions from a cardiologist. A therapist needs to know whether to monitor blood pressure and heart rate during exercise, and whether there are intensity ceilings they cannot exceed.
• Bone density — osteoporosis or osteopenia diagnosis, most recent DEXA scan results if available. This directly affects manual therapy techniques, resistance levels, and fall-risk categorization.
• Pregnancy — current pregnancy or recent delivery changes positioning, abdominal exercise, and manual therapy approach. Pelvic floor rehabilitation has its own intake considerations that overlap with but are distinct from general PT intake.

The intersection of medical history and HIPAA-compliant documentation is especially important in PT, where detailed health information flows between the clinic, the referring physician, and the insurance carrier. Every field you collect should have a clinical or billing purpose — collecting data you do not use creates HIPAA liability without clinical benefit.

Pain and functional assessment at intake

This is the clinical core of PT intake. The pain and functional assessment establishes the baseline against which all progress is measured. It is also the section that most directly supports authorization requests, because insurance companies approve treatment based on documented functional limitations, not on the patient’s subjective report that something hurts:

• Pain location — a body diagram where the patient marks pain areas is more useful than a text description. A patient who writes “my back hurts” could mean anywhere from the cervical spine to the sacrum. A body diagram with specific areas marked gives the evaluating therapist a visual starting point.
• Pain scale — a 0–10 numeric rating scale at intake, documented separately for rest, activity, and worst episode. A patient who reports 3/10 at rest and 9/10 with activity has a different clinical picture than a patient who reports 7/10 at rest and 8/10 with activity.
• Onset — when did the pain or limitation begin? Gradual onset suggests a different pathology than traumatic onset. A patient whose shoulder pain started three weeks ago after a fall needs different initial evaluation than a patient whose shoulder has been gradually worsening over eight months.
• Aggravating and relieving factors — what makes it worse, what makes it better. This is not just clinical information — it directly drives the home exercise program. If a patient reports that sitting aggravates their low back pain but walking relieves it, that data point shapes immediate intervention.
• Functional limitations — this is the field that insurance companies read most carefully. “Cannot climb stairs without handrail assistance.” “Unable to lift objects overhead above 5 pounds.” “Cannot sit for more than 20 minutes without standing to relieve pain.” These are specific, measurable limitations that justify treatment and create clear discharge criteria. A form that asks “describe your limitations” with a blank space will get vague answers. A form with checkboxes for common functional limitations plus a write-in field for specifics gets usable data.

Understanding how to structure these fields connects directly to the broader principles in what makes a good intake form — structured fields with checkboxes produce consistent, measurable data, while open-ended fields produce narratives that are harder to track over time.

Prior therapy history

Patients frequently arrive at a new PT clinic having already received physical therapy for the same or a related condition elsewhere. This history is clinically valuable and often ignored:

• Previous PT episodes for the same condition — where they were treated, for how long, and the outcome. A patient on their third course of PT for chronic low back pain is a different clinical challenge than a first-time patient with acute low back pain.
• What worked and what did not — specific interventions that helped (manual therapy, aquatic therapy, specific exercises) and those that were ineffective or made things worse. This saves the therapist from repeating failed interventions and gives them a head start on what the patient responds to.
• Home exercise compliance history — did the patient follow through with their home exercise program in previous episodes? If not, why? Time constraints, pain with exercises, confusion about technique, or lack of motivation? This tells the therapist whether to invest heavily in a complex HEP or start with a minimal, highly achievable program and build from there.
• Reason for discontinuation — did the patient complete their course of care, or did they drop out? Insurance ran out, transportation problems, felt better and stopped, did not feel it was helping, scheduling conflicts. Each reason tells a different story about what will determine success or failure this time.

Insurance and authorization

Physical therapy has one of the most complex insurance landscapes in outpatient healthcare. Your intake must capture the information that the billing department and front desk need to verify coverage and obtain authorization before treatment begins. For a deeper look at insurance workflows at intake, see the insurance verification guide:

• Insurance verification — primary and secondary insurance carrier, policy number, group number, subscriber name and relationship to patient, subscriber date of birth. Many PT patients are covered under a spouse’s or parent’s plan, and the subscriber information is frequently incomplete at intake.
• Pre-authorization requirements — does the plan require pre-authorization for PT? How many visits are authorized initially? What is the process for requesting additional visits? This information should be verified before the first visit, but capturing it on the intake form ensures the clinical team is aware of the authorization window.
• Visit limits — annual visit caps (many plans limit PT to 20–60 visits per year), remaining visits if the patient has already used some with another provider, and whether visits are shared across rehabilitation disciplines (PT, OT, and speech therapy often draw from the same pool).
• Copay and coinsurance — per-visit copay amount, coinsurance percentage, deductible status (met or unmet, and remaining amount). Patients deserve to know their out-of-pocket cost before they commit to a treatment plan, and the intake is where that conversation starts.
• Workers’ compensation claim number — if the injury is work-related, the entire billing pathway changes. Workers’ comp requires a claim number, date of injury, employer information, and adjuster contact information. Missing any of these at intake delays reimbursement and can result in the claim being denied.
• Auto accident PIP/med-pay — motor vehicle accident patients often have personal injury protection (PIP) or medical payment coverage through their auto insurance. This is primary to their health insurance for accident-related treatment. Capture the auto insurance carrier, claim number, date of accident, and attorney information if applicable.

The complexity of PT insurance underscores why intake in regulated industries demands structured, field-specific forms rather than generic templates — a missed authorization number or an unverified visit limit creates billing problems that cascade for months.

Treatment goals: patient goals versus clinical goals

This is where physical therapy intake diverges most sharply from other healthcare intake processes. PT is inherently goal-oriented, and the intake must capture two distinct types of goals that serve different purposes but must align with each other:

Patient functional goals. These are the outcomes the patient cares about, expressed in their own language. “I want to be able to pick up my grandchild without pain.” “I need to return to work as a carpenter by August.” “I want to play recreational basketball again.” “I want to walk to the mailbox without my walker.” These goals matter because they drive patient motivation and engagement. A patient who does not see the connection between their exercises and their functional goal will stop doing the exercises.

Clinical goals. These are the measurable, objective targets the therapist sets based on the evaluation: achieve 140 degrees of shoulder flexion, improve knee extension to 0 degrees, increase single-leg stance time to 30 seconds, reduce pain from 7/10 to 3/10 with activity. Clinical goals are what the therapist documents in progress notes and what the insurance company evaluates when deciding whether to authorize additional visits.

The intake form should capture both. Patient goals go on the intake as the patient writes them — in their own words, reflecting what they actually want from therapy. Clinical goals are established during the evaluation session but should be documented alongside the patient goals so that the plan of care explicitly connects the two. When a patient’s goal is “return to tennis” and the clinical goal is “achieve 90% shoulder strength compared to uninvolved side,” the link between the two creates a treatment narrative that is both clinically sound and meaningful to the patient.

This approach to setting expectations at intake applies across healthcare but is especially critical in PT, where treatment often spans weeks or months and patient adherence depends on understanding why they are doing what they are doing.

Work-related injury intake

Workers’ compensation cases require their own intake section because the documentation requirements are fundamentally different from standard health insurance cases:

• Employer information — company name, address, supervisor name and contact information, HR department contact. The employer is a stakeholder in the treatment outcome, and communication with the employer (with patient consent) is often required.
• Job description and physical demands — a detailed description of what the patient does at work. Lifting requirements (frequency and weight), standing or sitting duration, repetitive motions, environmental exposures. The functional capacity evaluation that often follows PT is measured against these specific job demands.
• Modified duty availability — can the employer offer modified or light-duty work? This affects the treatment timeline and discharge planning. A patient with a modified-duty option may return to work sooner in a limited capacity while continuing therapy, whereas a patient with an all-or-nothing employer faces a longer full-disability period.
• Workers’ comp carrier and adjuster — carrier name, claim number, adjuster name, phone, and fax. The adjuster is the person authorizing treatment and approving visit extensions. Their contact information is not optional.
• Date and mechanism of injury — exactly when and how the injury occurred. “Lifted a 60-pound box from the floor to a shelf overhead on March 15, felt immediate sharp pain in the lower back” is the level of specificity workers’ comp documentation requires.

Sports medicine intake

Patients referred for sports-related injuries or performance rehabilitation need additional intake fields that capture the athletic context of their condition:

• Sport and activity level — which sport or activity, and at what level. A Division I college pitcher has different treatment expectations and timelines than a weekend recreational golfer, even if the diagnosis is the same.
• Position and dominant side — a quarterback’s throwing shoulder is a different clinical priority than a lineman’s shoulder with the same diagnosis. A right-handed tennis player with a right elbow injury has different return-to-play implications than the same injury on their non-dominant side.
• Competitive versus recreational — competitive athletes often have external pressures (team commitments, scholarship requirements, contract obligations) that influence their willingness to follow conservative treatment timelines. This is information the therapist needs at intake, not information to discover in week three when the patient admits they have been practicing against medical advice.
• Training schedule and season timing — is the patient in-season, off-season, or pre-season? A pre-season injury with twelve weeks until the first game has a different treatment intensity than a mid-season injury where the athlete is missing games.
• Return-to-play expectations — what does the patient (and their coach, if applicable) expect in terms of timeline? These expectations need to be documented at intake so the therapist can address unrealistic timelines early rather than facing a confrontation when the athlete is not cleared at the arbitrary deadline they had in mind.

Pediatric PT intake

Children are not small adults, and pediatric PT intake requires information that does not appear on any adult form:

• Developmental milestones — when the child rolled, sat, crawled, walked, spoke first words. Delays in motor milestones are often the reason for the referral, and the pattern of delays (gross motor only, fine motor only, or global) shapes the evaluation approach.
• School accommodations — does the child receive accommodations at school? Modified PE, adaptive seating, use of assistive devices, extra time for transitions between classes. School-based functional limitations are the pediatric equivalent of the adult “functional limitations” section.
• IEP or 504 plan status — is the child on an Individualized Education Program that includes PT or OT services? If so, the outpatient PT plan of care needs to complement, not duplicate, school-based services. The intake should capture whether school-based therapy is in place and the frequency.
• Parent goals versus clinical goals — parents often have specific functional goals for their child (“I want her to be able to ride a bike with her friends” or “I want him to be able to climb the playground equipment at recess”) that differ from but should align with clinical goals (improve core strength, bilateral coordination, dynamic balance). Capturing parent goals at intake ensures the therapist is working toward outcomes the family actually values.

The discharge planning question

Most clinicians think of discharge planning as something that happens at the end of treatment. In physical therapy, it should start at intake. Capturing expected discharge criteria at the beginning of the episode of care creates measurable treatment endpoints that serve both clinical and insurance purposes:

Discharge criteria established at intake. What does “done” look like for this patient? If the intake documents that the patient’s functional goal is to climb a flight of stairs without pain and the clinical goal is to achieve full knee extension and 120 degrees of flexion, then discharge criteria are already defined. The treatment plan works backward from those endpoints, and every progress note can reference them.

Insurance justification. When you request additional visits and can demonstrate progress toward intake-documented discharge criteria — “patient has progressed from 90 degrees to 110 degrees of flexion against a discharge criterion of 120 degrees” — the authorization request tells a clear, data-driven story that reviewers can follow.

Patient expectation management. A patient who knows from day one that treatment will conclude when they meet specific functional benchmarks is less likely to develop an open-ended dependency on therapy and more likely to engage actively in their home exercise program.

Fall risk screening at intake

Fall risk screening at intake serves both clinical and administrative purposes. For patients referred for balance, gait, or general deconditioning, documenting fall risk at intake establishes the baseline severity and justifies the intensity of the intervention:

• Fall history — number of falls in the past 6 and 12 months, circumstances (tripping, loss of balance, dizziness, lower extremity weakness), resulting injuries (fractures, head injury, hospitalization). Documented fall history is the strongest predictor of future falls and the strongest justification for balance-focused PT.
• Standardized screening tools — the Timed Up and Go (TUG), Berg Balance Scale, or Functional Gait Assessment scores documented at intake provide objective baseline measurements. A TUG score above 13.5 seconds at intake is a documented fall risk that supports treatment authorization. The same score at discharge, if improved, demonstrates measurable outcomes.
• Home environment factors — stairs in the home, use of assistive devices (cane, walker, rollator), grab bars in the bathroom, throw rugs, lighting quality. These are not clinical measurements, but they are fall risk factors that the therapist needs to know about when designing a home exercise program and making home modification recommendations.
• Fear of falling — self-reported fear of falling is an independent risk factor that limits mobility and activity even in patients with adequate physical capacity. A patient who can physically climb stairs but avoids them out of fear has a different treatment plan than a patient who physically cannot climb stairs.

Structuring PT intake for clinical and administrative success

The physical therapy intake form sits at the intersection of clinical care, insurance administration, and patient engagement. A form that captures only demographics and insurance information misses the clinical data that drives the treatment plan. A form that captures only clinical data leaves the front desk scrambling for authorization information. And a form that ignores the patient’s own goals produces a treatment plan that the patient does not feel invested in.

The most effective PT intake forms are the ones that connect every field to a purpose: clinical decision-making, insurance justification, or patient engagement. When a field does not serve at least one of those purposes, it does not belong on the form. When a field serves all three — like the functional limitations section — it deserves the most structured, detailed capture format you can design.

If you are building intake documentation across a healthcare or rehabilitation practice, the Healthcare Bundle includes physical therapy alongside 20 other healthcare and wellness categories, each with profession-specific intake and questionnaire fields designed for clinical, billing, and compliance requirements.