Every practice has an intake form, and most were inherited: a PDF someone made years ago, passed between colleagues, added to whenever a situation went wrong and never shortened. The result asks a patient with a sore knee about their dental history and does not ask what they are hoping to be able to do again.
What the form is actually for
An intake form has three jobs, and a field that does not serve one of them is a field to delete:
- Save time in the room. Anything the patient can type at home should not be typed by you during a session you are paid for.
- Make you safer. Red flags, medication, comorbidities, recent surgery. This is the part that belongs on every form regardless of specialty.
- Give you a baseline. A starting point you can compare against in six weeks, in numbers rather than impressions.
The fourth job it is often asked to do — look thorough — is the reason most forms are twice as long as they need to be.
What to collect before the patient arrives
Send this ahead. It is the administrative and historical layer, and none of it needs you in the room:
| Section | What to ask |
|---|---|
| Identification | Name, date of birth, contact details, emergency contact, and whatever identifier your billing needs |
| The complaint | What hurts, how long, how it started, what makes it better or worse, in their words |
| History | Previous episodes, surgery, imaging, other conditions being treated |
| Medication | Current medication including anticoagulants and corticosteroids, and allergies |
| Red flags | Unexplained weight loss, night pain, fever, bladder or bowel changes, trauma, cancer history |
| Life and activity | Occupation, physical demands, sport and exercise, what the day looks like |
| Goals | What they want to be able to do again — the single most useful question on the form |
| Consent and privacy | Treatment consent, how you handle their data, how they can withdraw it |
The goal question is worth writing carefully. “What would you like to get out of physiotherapy?” produces “get better”. “What is something you have stopped doing because of this problem?” produces “I cannot pick up my grandson” — which is a treatment goal, a discharge criterion and the thing the patient will remember you for.
The initial assessment itself
This is the part you complete in the room, and it is a clinical document rather than a questionnaire. Structure varies by training and by setting, but the elements that a later reader — a colleague, an insurer, a regulator, you in two years — will look for are consistent:
- Subjective: the history as you took it, including what the patient said in their own words.
- Observation: posture, gait, swelling, asymmetry, whatever is relevant to the region.
- Objective measures: range of motion in degrees, strength grades, girth, distances, times. Numbers, not adjectives.
- Special tests performed, and the result of each — including the negative ones.
- Pain: location, character, a rating on a defined scale, and what changes it.
- Functional status: what the person can and cannot do, and any outcome measure you have used.
- Clinical reasoning: your working hypothesis, stated plainly. This is the section most often skipped and the one that explains your decisions later.
- The plan: what you intend to do, expected frequency and duration, and how you will know it is working.
- What the patient was told, including home exercise and advice.
Baselines and outcome measures
A baseline is what turns “they seem better” into evidence. Pick one or two measures per condition, record them at assessment, and repeat them at the same interval every time — a measure taken once is decoration.
- A pain rating on a fixed scale, recorded the same way every session so the numbers are comparable.
- Range of motion in degrees, measured in the same position, by the same method.
- A functional test with a number: sit-to-stand repetitions, timed walk, single-leg stance time, grip strength.
- A region-specific questionnaire if you use one, scored and dated.
- The patient’s own goal, rated for how close they are to it.
Set the re-assessment date at the first session, not when you happen to remember. Four to six weeks is usual.
A plan with no review date tends to run until the patient stops coming, which is not the same thing as finishing treatment.
Consent, and recording it properly
Consent is not a signature box; it is a record that a conversation happened. What a later reader needs to see is what was explained, what was agreed, and when.
- General treatment consent at intake, covering the assessment and the episode of care.
- Specific consent in the session note for anything higher risk, invasive, or involving clothing removal — with the risks you described.
- Separate consent for anything that is not treatment: photographs, video, teaching, case studies, marketing. These need their own permission and their own withdrawal.
- Consent for minors or dependent adults recorded with who gave it and on what basis.
- Data consent kept distinct from treatment consent, because a patient can withdraw one without withdrawing the other.
Five ways intake forms go wrong
- Too long. Four pages produce rushed answers and abandoned forms. If a field has never changed a decision, remove it.
- Open text everywhere. Free text is hard to complete and impossible to compare. Use choices where choices exist.
- Collecting data you do not need. Every extra personal detail is something you must protect, justify and eventually delete.
- No goal question, so treatment gets aimed at a symptom rather than at something the patient wanted back.
- Never reviewed in the room. The form is a prompt for the conversation, not a substitute for it — and what patients write down is frequently not what they mean.
Send the form before the patient arrives
Build your own intake form, share the link, and have the answers waiting on the record when they walk in.
Create a free account → No credit card. The first 7 days have no limits at all.Paper, PDF or a link
Paper works and is still common. Its costs are the ones nobody counts: someone transcribes it, the handwriting is ambiguous, and you are now storing identifiable health data in a cabinet that has to be locked, retained for years and eventually destroyed properly.
A PDF sent by email is usually worse than both alternatives. In practice the patient cannot fill it in on a phone, so it gets printed, signed, photographed and emailed back as three crooked images — or, more often, not returned at all.
A form the patient opens as a link and completes on a phone is the one that actually comes back. What matters is that the answers land on the patient’s record rather than in your inbox, so nobody has to retype them.
Adapting the form to what you treat
The identification, history, medication, red-flag and consent sections are the same for everyone. The assessment section is not:
- Musculoskeletal and sports: mechanism of injury, training load and recent changes to it, return-to-sport target.
- Post-operative: date and detail of surgery, the surgeon’s protocol, restrictions and their end dates.
- Neurological: functional independence, transfers, mobility aids, falls history, home environment.
- Respiratory: breathlessness scale, cough and secretions, oxygen use, exercise tolerance.
- Paediatrics: birth and developmental history, school, who has parental responsibility.
- Pelvic health: obstetric history and a consent conversation recorded with more care than usual.
Two or three templates that fit what you actually see beat one universal form that fits nothing well.
Building the form in Physioly
Physioly has both halves of this. The clinical record carries a full assessment — history, medication, comorbidities, pain ratings, range of motion, functional tests, a body map, treatment plan, patient advice and a re-assessment date — and you can build your own assessment templates rather than using ours, so the fields match how you were taught to work.
For the pre-arrival part there is a pre-assessment form you build yourself, with text, number, date, choice, multiple-choice, yes/no and scale fields, plus your own opening and closing message. You share it as a link, the patient completes it on their phone, and the answers arrive attached to the record instead of in your inbox.
What to be aware of: the form link is shared by you — the system prepares the message, sending it is a normal message from your own phone, and there is no automatic dispatch on any channel. There is no handwriting recognition for scanning old paper forms, and no e-signature with a certificate; a signature captured on a form is a record of agreement, not a qualified digital signature. If your regulator requires the latter, that is a question to settle before you commit to any product, ours included.
Questions we get asked
What should be included in a physiotherapy intake form?
Identification and contact details, the presenting complaint in the patient’s own words, how long it has been going on and what makes it better or worse, relevant medical history, current medication, previous surgery and imaging, red-flag screening questions, occupation and activity level, what the patient wants to be able to do again, and consent. Anything that does not change your assessment or your plan does not need to be there.
Should patients fill in the form before the first appointment?
Wherever possible, yes. Administrative and historical information collected beforehand turns the first session into assessment rather than typing, and patients answer questions about their own history more accurately at home than under time pressure in a clinic. Always review it in the room — what was written down and what the patient means are not always the same thing.
How do I record consent for physiotherapy treatment?
Record what was explained, what the patient agreed to, and when. A signature on a form at intake covers the episode in general terms; specific consent for anything invasive or higher risk should be recorded in the note for that session, along with the risks discussed. Consent obtained once and never revisited is weak evidence if it is ever examined.
Is one assessment form enough for every patient?
The core of it is the same for everyone, but the assessment section usually is not. A paediatric first visit, a post-operative knee and a persistent low-back-pain case need different measures and different questions. Most practices end up with a shared core and two or three specific templates rather than one form that tries to serve all of them.
Can a physiotherapy intake form be completed on a phone?
It should be, because that is what most patients will use. Keep questions short, avoid open text boxes where a choice would do, and make the form work in a browser rather than as a PDF that has to be printed, signed, photographed and emailed back — which is how a form quietly stops being completed at all.