Below are two free physical therapy intake form templates you can check out or download. One is a comprehensive four-page new patient packet, the other is a focused two-page health history form.

Both are adapted from real forms that physical therapists have shared in Jane’s template library, and both are available as a Google Doc or fillable PDF.

Two physical therapy intake form templates

Each template is available as a Google Doc (open the link and select File > Make a Copy to save your own editable version) and as a fillable PDF.

Full PT intake form

A full four-page new patient packet covering primary area of concern, a body chart, pain rating, activity and sleep patterns, health history by system, current medications, imaging history, and an out-of-network agreement. Best for practices starting from scratch with their forms or someone who wants everything collected in one place vs separate forms.

PT health history form

A more focused two-page form covering chief complaint, health and medical history organized by body system, current medications, previous surgeries, and a brief informed consent clause. Best for practices that already have billing and consent forms handled elsewhere and want a clean standalone PT focused health history document.

What’s included in the PT intake form templates?

Here’s a quick look at some key sections these templates cover and why they’re helpful for PTs.

Primary area of concern and body chart

The longer full intake form opens with a structured region selector (neck and head, shoulder or arm, low back and pelvis, hip or knee, foot and ankle, or other), followed by a body diagram where patients mark where their symptoms are. A region selector plus a diagram beats an open text field because it gives you a solid starting point for the evaluation and saves you some time at the start of the session.

Chief complaint and injury history

Both of the free templates above capture the presenting issue and any related accidents, injuries, or surgeries. The comprehensive form also asks whether prior imaging has been done. That question is easy for patients to answer, and it saves you from discovering mid-evaluation that an MRI or X-ray exists somewhere you could have access to and review.

Pain rating

The above full intake form option includes a 0-to-10 average pain scale for the past week. Capturing this during intake gives you a documented baseline to measure progress against throughout the time of care, which is exactly the kind of objective, repeatable measure that supports your clinical documentation later. If your practice tracks outcomes more formally, intake is a good place to add validated outcome measures alongside the pain scale.

Health and medical history by system

Both forms organize health history by body system rather than in a single open field, which makes it less likely that a patient will forget to add something relevant. The comprehensive form goes deeper here, with a full system-by-system breakdown covering musculoskeletal, cardiovascular, respiratory, digestive, nervous, head and ENT, reproductive and urinary, immune and lymphatic, integumentary, mental health, and women’s health. The health history form takes a lighter touch, grouping conditions into broader categories to keep the form focused.

Activity and sleep patterns

The full PT intake form includes an activity section (occupation, hobbies, and exercise frequency) and a sleep section (hours per night, wake frequency, sleep position, and whether sleep feels restful). For patients whose pain patterns might connect to how they move, sleep, or spend their days, having that information collected in detail upfront gives you a fuller picture.

Current medications, supplements, and allergies

Both form templates collect information on current medications and prior surgeries. The full new patient intake form also asks separately about allergies to medications, foods, and adhesives. The adhesive allergy question is good to know before you reach for tape or an electrode pad in a hands-on session.

Consent and financial agreement

Each template includes consent language, with the comprehensive form also adding financial and out-of-network agreement sections. Either way, best to treat both as a starting point and review against your state regulations before you start sending. If you offer dry needling, that usually requires its own written consent separate from your general consents. The APTA’s state-by-state dry needling map confirms whether it applies where you practice and what that consent needs to cover.

Which template makes sense for my practice?

If you already have consent and billing handled and just need a clean, standalone health history document to add to what you’ve got, start with the health history form. It’s focused, two pages, and quick to customize.

If you’re building or rebuilding your intake from scratch and want primary complaint, health history, consent, and billing info all collected in one place, check out the full PT intake form.

If you’re not sure, the full intake form is probably the safer form to grab. It’s pretty easy to trim down a section later if you find you’re getting back more info than you need.

How can I customize the intake templates for my practice?

The templates linked out above are meant to be edited, and in practice, most clinics change at least a few things before they send their first one.

Here are a few things to take care of before you send either form.

Add your practice name and logo before sending

The intake form is one of the first things a new patient interacts with. Adding your logo, clinic name, and brand colors makes it feel like yours. This should only take a few minutes in your own copy of the Google Doc.

Adjust the consent and billing language for your state and scope of practice

The consent and billing language in both templates is a starting point. Before you send either form, review the language against your state regulations, your professional association’s guidance, and your own policies before you send the form. Depending on how your practice bills, you may want to add more financial policies as well, like an assignment-of-benefits clause.

Remove the fields that don’t apply to you

A shorter, more focused form still gets you the information you need, and it’s easier for patients to fill out. A hand and wrist therapy practice probably doesn’t need an overly detailed low back and pelvis section. A pediatric clinic will want to swap occupation and exercise frequency for details more relevant and age-appropriate. The same goes for the system-by-system health history, feel free to trim any rows that fall outside your scope or patient population

Decide how and when you’ll send it

Sending the intake form at the time of booking gives patients the most time to fill it out at home and also gives you a chance to review their history before they arrive. A fillable PDF works for this, though you’ll want a secure way to send it, receive it and store it.

Just keep in mind that your standard unencrypted email doesn’t meet the safeguards HIPAA requires for sending patient health information. You’ll want to use a secure, encrypted method instead.

The easiest option is an EMR that can send and receive forms securely when a patient books. If you’re not using an EMR, you could look for a secure file-sharing or form tool that meets your regional privacy requirements instead.

FAQ

Do physical therapists need a separate intake form for Medicare patients?

No, Medicare doesn’t require a separate intake form for Medicare patients. What it requires is that your medical record show that the services were “reasonable and necessary,” and a thorough intake form is a helpful start for building that record.

To get specific, under Chapter 15, Section 220 of the Medicare Benefit Policy Manual, this means documenting both current functional status and a clear clinical picture of the patient’s primary complaint.

If you bill Medicare, check the current requirements with your Medicare Administrative Contractor (MAC) before finalizing your form, since Local Coverage Determinations (LCDs) can add requirements beyond the federal baseline.

Do I need a patient’s signature on a physical therapy intake form?

Yes, it’s generally best practice. Most regulatory and professional standards require a signature on anything that captures consent, whether that’s consent to treat, a financial agreement, or acknowledgment of your privacy notice.

And a heads up, for US practices covered by HIPAA, the Notice of Privacy Practices (NPP) acknowledgment is its own requirement, not something that folds into your general consents. A separate dedicated field for it on your intake form makes that distinction easy and clear.

In practice, many clinics use checkboxes for each individual acknowledgement throughout the form and then a single signature at the end that covers everything. That approach keeps the form readable while still creating a clear record that the patient reviewed and agreed to each section. If you’re sending forms digitally, it’s good to confirm that your platform captures a valid electronic signature.

Are these templates usable for Canadian physiotherapy practices?

The health and system-based sections are useful to PTs anywhere. The consent language and the out-of-network agreement, though, are written for US practice. Canadian physiotherapists will likely want to make some changes to the forms to reflect PIPEDA and provincial legislation, billing and the language of their regulatory college before using either form.

These templates should be used as a starting point. Requirements vary by region and licensing body, so be sure to check which regulations apply to your practice before you send either form. Our guide to new patient intake forms gives more details on what else you could think about including.