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It captures the primary area of concern, additional concerns, accident/injury and surgery history, prior imaging, and average pain rating over the last week. The form also records current medications and supplements, allergies, activity and recreational habits, sleep patterns, and current or prior therapies with frequency and recent appointment dates. It includes checkboxes for musculoskeletal, cardiovascular/respiratory, digestive, nervous, head/ENT, reproductive/urinary, immune/lymphatic, integumentary, mental health, and women’s health conditions, plus space to elaborate. It further asks for treatment goals and includes an out-of-network payment agreement.","Physical Therapy Intake Form  \n\n| Primary Area Of Concern (Select One) |\n| --- |\n| ☐ Neck, Jaw, Head (may include shoulder/arm/mid-back)\u003Cbr>☐ Shoulder or Arm (no neck involvement)\u003Cbr>☐ Low Back, Pelvis, Hip (may include mid-back)\u003Cbr>☐ Hip or Knee (no low back involvement)☐ Foot, Ankle, or Calf\u003Cbr>☐ None of the above (Such as gait, balance, mobility. Please describe.) |\n| Body Chart\u003Cbr>|\n\n\n| Additional Concern(s) |  |\n| --- | --- |\n| Please list any accidents, injuries, or surgeries related to this concern. |  |\n| Have you had any imaging done of these or other areas\u003Cbr>(ex. X-ray, MRI, CT, etc.)? |  |\n| Rate your AVERAGE pain over the last week. | ☐ 0 (no pain) ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 ☐ 7 ☐ 8 ☐ 9 ☐ 10 (emergency room) |\n| Please list any medications or supplements you are CURRENTLY taking. |  |\n\n1  \n\n| Please list ALLERGIES to any medications, foods, or adhesives. |  |\n| --- | --- |\n\n\n| Activity |  |\n| --- | --- |\n| What is your Occupation? |  |\n| Which recreational activities or hobbies do you enjoy? |  |\n| Describe your activity level or exercise frequency/type. |  |\n\n\n| Please tell me about your sleeping patterns. |  |\n| --- | --- |\n| Number of hours per night |  |\n| Number of times you wake per night |  |\n| Reason for waking |  |\n| ☐ Restful ☐ Restless ☐ Side sleeper ☐ Back Sleeper ☐ Stomach sleeper |  |\n\n\n| Are you currently receiving any of the following therapies? | ☐ Massage Therapy ☐ Chiropractic ☐ Physical Therapy ☐ Naturopathic Medicine ☐ Medical Doctor ☐ Other |\n| --- | --- |\n| If so, please indicate the frequency of these treatments and (approx) most recent appointment date |  |\n\n\n| Musculoskeletal System | ☐ Acute muscle and joint pain ☐ Back pain ☐ Spondylolisthesis ☐ Chronic muscle and joint pain ☐ Jaw pain ☐ Tendonisis/Bursitis ☐ Swollen/stiff joints ☐ Rheumatoid arthritis ☐ Scoliosis ☐ Numbness in arms or legs ☐ Osteoarthritis ☐ Artificial joints, pins, or wires |\n| --- | --- |\n| Cardiovascular/Respiratory System | ☐ Chest pains ☐ Low blood pressure ☐ Pneumonia ☐ Heart palpitations ☐ Stroke ☐ Emphysema |\n\n2  \n\n|  | ☐ Pacemaker ☐ Chronic cough/cold/flu ☐ Anaemia\u003Cbr>☐ Heart disease ☐ Shortness of breath ☐ Deep vein thrombosis ☐ Heart attack ☐ Asthma ☐ Varicose veins\u003Cbr>☐ High blood pressure ☐ Bronchitis |\n| --- | --- |\n| Digestive System | ☐ Painful bowel movements ☐ Increased food sensitivities ☐ Diabetes\u003Cbr>☐ Haemorrhoids ☐ Loss/increase in appetite ☐ Gall stones ☐ Chronic bloating ☐ IBS ☐ Hepatitis\u003Cbr>☐ Acid reflux ☐ Colitis ☐ Cirrhosis\u003Cbr>☐ Hiatal hernia ☐ Constipation ☐ Liver/Gall bladder dysfunctions ☐ Ulcer(s) ☐ Diarrhea\u003Cbr>☐ Nausea ☐ Crohn's disease |\n| Nervous System | ☐ Paralysis ☐ Numbness/tingling sensation ☐ Balance loss ☐ Epilepsy ☐ Fainting ☐ Degenerative disease |\n| Head/ENT | ☐ Headaches/Migraines ☐ Tinnitus/hearing loss or dysfunction ☐ Fatigue/Sleep disorder\u003Cbr>☐ Dizziness/Vertigo ☐ Congested sinuses\u003Cbr>☐ Chronic laryngitis/pharyngitis/tonsilitis\u003Cbr>☐ Loss of vision ☐ Loss of smell/taste ☐ Dental surgery ☐ Earaches ☐ Memory loss |\n| Reproductive/Urinary System | ☐ Kidney stones ☐ Urgency ☐ Prostate dysfunction ☐ Kidney failure ☐ Bladder prolapse ☐ Sexual dysfunction ☐ Painful urination ☐ Chronic urinary tract infections ☐ Incontinence ☐ Chronic yeast infections |\n| Immune and Lymphatic System | ☐ Edema ☐ Lymphedema ☐ Autoimmune disorder |\n| Integumentary System | ☐ Sensitive skin/rashes ☐ Eczema/psoriasis ☐ Acne ☐ Herpes ☐ Parasitic infections ☐ Dermatitis |\n| Mental Health | ☐ Anxiety ☐ Depression ☐ Bipolar disorder ☐ OCD ☐ Substance abuse ☐ ADD/ADHD |\n| Women's Health | ☐ Pain, heaviness, or irregular menstruation ☐ Abortion(s)☐ Cystic or tender breast tissue\u003Cbr>☐ Endometriosis ☐ D & C ☐ Breast feeding |\n| Use this area to elaborate on any checked boxes above |  |\n\n3  \n\n| What are your expectations or goals for receiving treatment? |\n| --- |\n|  |\n\nOut-Of-Network Agreement  \n☐ I understand that visits with my physical therapist may be out-of-network and payment by cash, check, or charge is expec","cbCaicSrIITBEFrx","https://ap.wps.com/l/cbCaicSrIITBEFrx","pdf",905996,4,"English","en",105,"# Primary Area of Concern\n# Additional Concern(s)\n# Activity and Occupation\n# Sleep Patterns\n# Current Therapies\n# System-Based Condition Checklists\n## Musculoskeletal System\n## Cardiovascular/Respiratory System\n## Digestive System\n## Nervous System\n## Head/ENT\n## Reproductive/Urinary System\n## Immune and Lymphatic System\n## Integumentary System\n## Mental Health\n## Women's Health\n# Treatment Expectations or Goals\n# Out-Of-Network Agreement","[{\"question\":\"How does the form ask you to choose your primary area of concern?\",\"answer\":\"You select one option in the “Primary Area Of Concern” section, such as neck/jaw/head, low back/pelvis/hip, hip/knee, foot/ankle/calf, or none of the above with a short description.\"},{\"question\":\"What information is collected about pain and related diagnostic history?\",\"answer\":\"You rate your average pain over the last week on a 0–10 scale, and you list any imaging done (e.g., X-ray, MRI, CT) for the current or other areas.\"},{\"question\":\"What does the out-of-network agreement require?\",\"answer\":\"It states visits may be out-of-network, payment is expected at the time of the visit (cash, check, or charge), and documentation for out-of-network benefit submission is available upon request.\"}]","Physical Therapy Intake Form - Template | PDF",1789851992,2,{"code":4,"msg":76,"data":77},"ok",{"site_id":69,"language":68,"slug":78,"title":59,"keywords":79,"description":60,"schema_data":80,"social_meta":134,"head_meta":136,"extra_data":138,"updated_unix":139},"physical-therapy-intake-form-template","",{"@graph":81,"@context":133},[82,96,116],{"@type":83,"itemListElement":84},"BreadcrumbList",[85,89,91,94],{"item":86,"name":87,"@type":88,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":90,"name":10,"@type":88,"position":74},"https://docshare.wps.com/template/",{"item":92,"name":36,"@type":88,"position":93},"https://docshare.wps.com/template/forms/",3,{"item":95,"name":59,"@type":88,"position":66},"https://docshare.wps.com/template/physical-therapy-intake-form-template/307616/",{"url":95,"name":59,"@type":97,"image":98,"author":103,"headline":59,"publisher":105,"fileFormat":108,"inLanguage":68,"description":60,"dateModified":109,"datePublished":110,"encodingFormat":108,"isAccessibleForFree":111,"interactionStatistic":112},"DigitalDocument",{"url":99,"@type":100,"width":101,"height":102},"https://docshare.wps.com/thumbnails/physical-therapy-intake-form-template/307616.png","ImageObject",442,249,{"name":57,"@type":104},"Person",{"url":86,"name":106,"@type":107},"DocShare","Organization","application/pdf","2026-10-25","2026-09-19",true,{"@type":113,"interactionType":114,"userInteractionCount":20},"InteractionCounter",{"@type":115},"ViewAction",{"@type":117,"mainEntity":118},"FAQPage",[119,125,129],{"name":120,"@type":121,"acceptedAnswer":122},"How does the form ask you to choose your primary area of concern?","Question",{"text":123,"@type":124},"You select one option in the “Primary Area Of Concern” section, such as neck/jaw/head, low back/pelvis/hip, hip/knee, foot/ankle/calf, or none of the above with a short description.","Answer",{"name":126,"@type":121,"acceptedAnswer":127},"What information is collected about pain and related diagnostic history?",{"text":128,"@type":124},"You rate your average pain over the last week on a 0–10 scale, and you list any imaging done (e.g., X-ray, MRI, CT) for the current or other areas.",{"name":130,"@type":121,"acceptedAnswer":131},"What does the out-of-network agreement require?",{"text":132,"@type":124},"It states visits may be out-of-network, payment is expected at the time of the visit (cash, check, or charge), and documentation for out-of-network benefit submission is available upon request.","https://schema.org",{"og:url":95,"og:type":135,"og:title":59,"og:site_name":106,"og:description":60},"article",{"robots":137,"canonical":95},"index,follow",{"doc_id":55,"site_id":69},1791149250]