Physical Therapy Intake Forms & Patient Questionnaires

The PT Intake Sets the Treatment Plan in Motion

A physical therapy evaluation is only as good as the information gathered before the patient gets on the treatment table. The referring diagnosis from the orthopedist might say "right shoulder pain" with an ICD-10 code, but the intake is where you learn that the patient had a rotator cuff repair six weeks ago, was non-compliant with the surgeon's home exercise program, has a desk job that requires overhead filing for two hours a day, and has a workers' compensation claim pending that requires functional capacity documentation. All of that changes how you structure the plan of care. These fillable PDF physical therapy intake forms are HIPAA-compliant and designed to capture the clinical, functional, and administrative information that outpatient PT clinics need before the initial evaluation begins.

Referral Source, Diagnosis, and Surgical History

In direct-access states, patients can self-refer for physical therapy without a physician's prescription, but insurance reimbursement often still requires a referral or plan-of-care signature from an MD within the first 30 days. The intake must capture whether the patient was referred by a physician (and which one), whether they are self-referring, and what their insurance authorization status is. The referring diagnosis and ICD-10 codes matter for billing, but the surgical history matters more for clinical decision-making. A patient presenting for knee rehabilitation after ACL reconstruction with a patellar tendon autograft is on a fundamentally different rehab timeline than one who had a hamstring autograft or an allograft. Post-operative total knee replacement patients need different weight-bearing progressions depending on whether the surgeon used cemented or uncemented fixation. Prior PT episodes for the same condition affect both the treatment approach and the insurance authorization: if the patient had 12 visits of PT for the same shoulder six months ago with a different provider, the carrier may scrutinize authorization for a second episode. The intake captures all prior therapy, surgical dates, and the surgeon's post-op protocol if available.

Functional Limitations and Patient-Reported Outcomes

The functional limitation section of the intake is what separates a useful evaluation from a billing exercise. "Pain in the right knee" is a symptom. "Unable to descend stairs without holding the railing, cannot kneel to play with grandchildren, unable to walk more than two blocks without stopping due to pain and swelling" are functional limitations that drive measurable goals. The intake form captures the patient's current functional deficits in their own words before the therapist translates them into objective measures. Pain location, intensity on a 0-10 numeric scale, quality (sharp, dull, burning, aching), aggravating and alleviating factors, and 24-hour pain pattern (worse in the morning, increases throughout the day, night pain that disrupts sleep) all need documentation. For patients involved in personal injury or workers' compensation cases, the intake must also capture their pre-injury functional baseline because the insurer or opposing counsel will eventually demand that comparison. Home exercise compliance from prior therapy episodes is worth asking about directly, because a patient who acknowledges they did not do their exercises last time needs a different motivational approach this time.

Work Status, Insurance, and Case Type

Whether the patient's condition is related to a work injury, an auto accident, or a general medical condition determines which insurance is primary and what documentation requirements apply. Workers' compensation cases require employer and carrier information, claim numbers, and the authorized treating physician's name. Motor vehicle accident cases require the auto insurance carrier, claim number, date of accident, and whether the patient has PIP (personal injury protection) or MedPay coverage. The intake also captures the patient's occupation and specific job demands, because "return to work" means something very different for a firefighter than for an accountant. Job descriptions, essential functions, and whether the employer offers modified or light-duty positions are all relevant to discharge planning. For the high school athlete with an ACL tear, the intake captures the sport, position, competitive level, and season timeline, because the goal is not just "full range of motion" but clearance to return to competitive play by a specific date. For the office worker with chronic neck pain who has never had imaging, the intake documents what conservative measures have been tried, whether the patient has seen any other providers, and any red-flag symptoms that might warrant referral back to the physician before initiating treatment.

Treatment Goals and Plan-of-Care Foundations

The initial intake is the foundation for the entire plan of care. Insurance carriers require functional goals that are specific, measurable, and tied to a timeframe. The intake captures the patient's own goals (which might be "I want to play golf again" or "I need to be able to lift my toddler without pain") and the clinical baseline against which progress will be measured. Prior medical history, including cardiac conditions, diabetes, osteoporosis, and medications that affect healing or exercise tolerance (blood thinners, beta-blockers, corticosteroids), must be documented for patient safety. Fall risk screening for geriatric patients, pregnancy status for female patients of childbearing age, and mental health history that might affect pain perception or compliance are all clinical intake items that belong in the initial paperwork. The questionnaire walks the patient through all of this before they arrive, so the therapist can spend the evaluation hour on hands-on assessment rather than form-filling.

Our Physical Therapy Intake Form & Patient Questionnaire set is available for $19.99 (complete set), $14.99 (intake form only), or $9.99 (questionnaire only). Every form is a fillable, HIPAA-compliant PDF that works in any PDF reader and prints cleanly for clipboard use in the clinic.