Physiotherapy Patient Intake Form Template

Collects contact details, pain and injury history, prior treatment, insurance card, and consent from new physiotherapy patients before their clinic visit.

Use this template free

When to use it

• Before a new patient’s first physiotherapy appointment
• When a patient reports a new injury or pain concern
• To gather treatment history and activities affected before an assessment
• When the clinic needs insurance card details in advance

What it asks

1. What is your full name?
2. What is your email address?
3. What is your phone number?
4. Where are you experiencing injury or pain?
5. When did it start?
6. How severe is your pain right now?
7. What activities are affected?
8. What treatment have you already tried?
9. Upload your insurance card
10. I consent to the clinic collecting and using this information for my physiotherapy care.

Why it should be encrypted

Pain and treatment history, contact details, and insurance information are private. Answers are encrypted in the respondent’s browser so SealForm cannot read them; limit access to clinic staff who need them for care or intake.

Tips

• Add a note about which image formats are accepted for insurance card uploads.
• Explain how patients can describe pain severity and which activities to include.
• Tell patients who at the clinic will review their answers and how to ask questions.

More Healthcare templates

• Appointment Request Form
• Authorization to Release Medical Records
• Chiropractic Intake Form
• Current Medications Form
• Dermatology Intake Form
• Insurance Information Update
• Medical History Form
• New Patient Intake Form

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