Physiotherapy Intake template

A physiotherapy intake form that arrives with the assessment already half done: the area being treated, how the problem started, a 1–10 pain rating, what it makes harder day to day, and any imaging. Two logic rules keep it short — the injury-details question appears only for a specific injury, and the upload only for patients who have actually had a scan.

Use this template Start free — no card

12 questions · works on the free plan (500 responses/month) · fully customizable

2 built-in logic rules
File upload question

What’s inside

The questions this template ships with — rename, reorder, or delete any of them in the builder.

01Your contact detailsContact info

02Date of birthDate

03Which area are we treating?Dropdown

04How did the problem start?Multiple choice

05When did it happen, and what were you doing?Short text

06How much pain are you in on a typical day?Rating scale

07What is it making harder right now?Checkboxes

08Have you had any imaging for this?Multiple choice

09Upload any scan reports or a referral letterFile upload

10What would you like to be able to do again?Long text

When to use this template

A physio clinic emailing intake with booking confirmations so the first session opens with hands-on assessment rather than history-taking
A sports rehab practice that needs the mechanism of injury and the date in writing before the athlete walks in
A post-surgical rehab service where scan reports and referral letters should arrive ahead of the patient
A multi-therapist clinic routing patients by body area — the dropdown sorts spinal from lower-limb caseloads

Tips to get more from it

The goal question is deliberately concrete — its description asks for "lift my toddler" rather than "get better." That answer is what the treatment plan gets written against, so keep the prompt
The upload accepts any file type, because scan reports arrive as PDFs, phone photos of a letter, and occasionally a DICOM viewer export
The activities checklist displays as a two-column grid with Other enabled, so a patient can tick stairs and sleeping and add their own in one pass
Zunoform does not offer a HIPAA Business Associate Agreement, so treat this as an administrative intake form and keep clinical records in the system that holds your patient charts

Questions people ask

What should a physiotherapy intake form ask before the first appointment?

Body area, how the problem started and when, a pain rating, which daily activities are affected, imaging history, and the patient's own goal. This template asks all seven and hides the injury-date and upload questions when they don't apply.

Can patients upload their scan reports or referral letter?

Yes — the upload takes up to three files of any type at 10 MB each, and it only appears for patients who said they've had imaging.

Is this form suitable for protected health information under HIPAA?

Zunoform does not offer a HIPAA Business Associate Agreement, so we would not describe it that way. The template is built for administrative intake ahead of a visit. If your practice needs a signed BAA, choose a vendor that offers one.