By the Templateez Team · Licensed Attorney · June 2026

Physical Therapy Intake Forms: What Every PT Clinic Needs to Capture

Most physical therapy clinics start with a generic medical intake form and bolt on a few extra questions. It works—until it doesn't. You end up chasing down referral details mid-eval, discovering the patient is on warfarin after you've already planned aggressive soft tissue work, or realizing nobody asked about prior PT episodes for the same shoulder that's been surgically repaired twice.

A PT-specific intake form isn't a nice-to-have. It's the difference between walking into your initial evaluation prepared and spending the first fifteen minutes doing detective work.

Referral Source and Physician Orders

This is where PT intake diverges from a standard medical form immediately. You need to know whether the patient has a physician referral or is coming in under direct access—and your form needs to handle both scenarios cleanly.

If there's a referring physician, capture the provider name, NPI, phone, fax, and the specific referral diagnosis. If your state allows direct access, you still need to document it. Most direct-access states impose visit caps or evaluation-only restrictions before a physician referral is required, and those limits vary. Your intake form should flag whether the patient is self-referred so your front desk knows immediately whether a plan-of-care signature will be needed.

Diagnosis and ICD-10 Codes

A generic intake form asks "reason for visit." A PT intake form needs the actual diagnosis and ICD-10 code from the referral, because that code drives your billing from day one. If the patient arrives without a referral code, your form should still capture the primary complaint in enough detail that you can assign an appropriate code during the evaluation.

Include fields for both the primary and secondary diagnoses. Shoulder impingement doesn't tell the whole story if the patient also has cervical radiculopathy contributing to the presentation. Payers will deny claims when the diagnosis code doesn't match the treatment provided—getting this right at intake saves your billing team hours downstream.

Pain Assessment and Clinical Documentation

A numeric pain scale (0–10) is a starting point, but PT clinics need more. Capture pain at rest, pain with activity, and worst pain in the last 24 hours. These three numbers tell a different story than a single rating. A patient who reports 3/10 at rest but 9/10 with overhead reaching gives you actionable information before you've even touched them.

Many PT clinics supplement their intake form with a separate body diagram — a printable outline where patients mark the location, type, and radiation pattern of their pain. Consider using a standalone pain-mapping tool alongside your intake; it creates a visual baseline you can reference across the episode of care and catches things patients forget to mention verbally — the knee pain they consider secondary to the hip complaint that's actually driving their gait deviation.

Functional Limitations

This is the section generic medical forms miss entirely. You need to know what the patient can't do, not just what hurts.

Activities of Daily Living

Can they dress independently? Reach overhead into cabinets? Get in and out of the shower? Sleep through the night? These functional markers drive your treatment goals and give payers the medical necessity documentation they require for authorization.

Mobility and Ambulation

Capture current assistive device use (cane, walker, wheelchair), weight-bearing status if post-surgical, fall history in the last 12 months, and distance tolerance. A patient who reports they "can walk fine" but then tells you they haven't left their house in three weeks because they can't manage the front steps—that's the kind of detail a structured form pulls out.

Work and Sport Demands

If the patient needs to return to a physically demanding job or sport, you need the specifics at intake. A warehouse worker who lifts 50-pound boxes overhead is a different rehab trajectory than a desk worker with the same rotator cuff repair. Capture the job title, physical demands, and whether there's a work comp claim or return-to-play requirement involved.

Prior PT Episodes and Surgical History

Ask specifically whether the patient has had physical therapy for this same condition before. If yes, where, when, what worked, and what didn't. Knowing they did six weeks of PT at another clinic with no improvement changes your clinical reasoning on day one. Maybe they need a different approach. Maybe the diagnosis is incomplete.

Surgical history should be filtered for relevance. You don't need to know about an appendectomy from 2008 (though a general medical history section can capture that). You do need to know about the two prior arthroscopies on the shoulder you're about to treat, the spinal fusion three levels above the segment they're now complaining about, or the total knee replacement on the contralateral side that's affecting their gait compensation patterns. For foot and ankle conditions specifically — especially diabetic patients requiring vascular screening and CMS risk stratification — see our podiatry intake guide.

Medications That Affect Treatment

When a patient's recovery involves both physical and occupational therapy, the OT intake captures the functional and ADL dimensions that PT forms don't cover — see our occupational therapy intake guide for the motor, sensory, and self-care assessment fields that complement a PT evaluation.

A generic medication list is fine for a primary care visit. For PT, you need to flag specific categories that directly change how you treat:

• Blood thinners (warfarin, Eliquis, Xarelto)—affects your manual therapy intensity, dry needling decisions, and bruising risk
• Muscle relaxants (Flexeril, Baclofen, Zanaflex)—masks tone and guarding, alters your assessment findings
• Pain medications (opioids, gabapentin, NSAIDs)—a patient who took 10mg of oxycodone an hour before their eval will present very differently at their next visit
• Corticosteroid injections—recent injection timing changes tissue integrity and your exercise progression timeline

Your intake form should call these out explicitly, not bury them in a general medication list your clinician has to sift through chair-side.

Insurance Authorization and Visit Limits

PT billing is authorization-driven in a way that most medical specialties aren't. Your intake form needs to capture:

• Whether pre-authorization was obtained (and the auth number)
• Number of visits authorized
• Authorization expiration date
• Whether the patient has a therapy visit cap on their plan (many commercial plans cap at 20–30 visits per year across PT/OT/ST combined)
• Co-pay and co-insurance amounts the patient is responsible for

Capturing this at intake prevents the ugly surprise at visit 12 when your front desk discovers the authorization expired two weeks ago. For clinics that treat both PT and occupational therapy patients, shared visit caps make this doubly important. Build it into the form so it's documented before the first treatment session.

Patient Goals

Medicare requires patient-centered goals in the plan of care. But beyond compliance, asking patients to state their own goals at intake gives you something a clinician-generated goal list doesn't—what actually matters to them.

"Return to playing tennis twice a week" is a goal your patient cares about. "Increase shoulder flexion ROM to 160 degrees" is a goal you care about. Both belong in the plan of care, but only one drives patient engagement and retention. Capture their words at intake so you can reference them throughout the episode.

Common goal categories worth prompting for: return to sport, return to work (with or without restrictions), independence with daily activities, pain reduction to a specific functional level, and fall prevention.

Why Generic Medical Intake Forms Fall Short

A standard medical intake captures demographics, insurance, allergies, and a medication list. That covers maybe 30% of what a PT clinic needs at day one. It misses referral source tracking, ICD-10 fields, functional limitation grids, prior therapy history, authorization details, and patient goals entirely. Your clinicians end up capturing that information informally during the eval and scribbling it into their notes—or worse, not capturing it at all.

Building a PT-specific intake form means your clinicians start every initial evaluation with the information they need, your billing team has the authorization and diagnosis details upfront, and your documentation meets payer requirements from visit one. That's not overhead—it's the foundation your clinic runs on.

For a deeper look at how healthcare intake forms handle HIPAA requirements, see our guide on HIPAA-compliant intake forms. And if you're building out forms across your entire practice, the Healthcare Bundle covers 21 specialties including physical therapy, occupational therapy, and sports medicine.

PT clinics that deal with visit authorization limits, combined therapy caps, and re-authorization deadlines know how quickly billing falls apart when intake doesn't capture the right insurance details. Our guide on intake forms for insurance billing covers the authorization fields, coordination-of-benefits workflows, and denial codes that hit rehab providers hardest — especially when PT, OT, and speech share a single visit pool under the patient's plan.