About this template
A Physical Therapy Evaluation Form is an essential clinical assessment tool used by physical therapists to document a new patient's medical history, current symptoms, pain levels, and functional limitations. This structured assessment helps clinicians establish a baseline, understand injury onset, and formulate an effective, personalized rehabilitation plan.
Designed for seamless digital intake, this form captures vital patient information, occupational details, primary complaints, aggravating factors, and previous medical or surgical history. It also provides dedicated sections for recording specific clinical observations, such as range of motion, pain severity ratings, and patient-specific recovery goals.
Clinicians and rehabilitation clinics can use Doc2Form to instantly convert this comprehensive evaluation template into a ready-to-use Google Form. It streamlines the onboarding process, ensures consistent documentation across sessions, and securely collects the detailed clinical data needed to deliver exceptional patient care from day one.
Key features
- Capture complete medical history and injury details in one organized workflow.
- Record precise pain severity ratings and aggravating factors.
- Document patient goals and clinical treatment plans efficiently.
- Easily shareable with patients for pre-appointment completion via Google Forms.
Use cases
- Initial patient intake at outpatient physical therapy clinics.
- Post-surgical orthopedic rehabilitation assessments.
- Sports injury evaluations for athletes and active individuals.
- Home health physical therapy consultations and baseline reviews.
What this form collects
- Full Name (Short answer)Enter your first and last name.
- Date of Birth (Date)Select your date of birth (MM/DD/YYYY).
- Age (Short answer)Enter your current age in years.
- Gender (Multiple choice)Select your gender identity.
- Phone Number (Short answer)Enter the best contact number for appointment reminders.
- Email Address (Short answer)Enter your primary email address.
- Home Address (Paragraph)Enter your complete mailing address.
- Occupation (Short answer)What is your current occupation or daily work activity?
- Marital Status (Dropdown)Select your marital status.
- Initial Patient Complaints (Paragraph)Describe your primary symptoms, pain locations, or reason for seeking physical therapy today.
- Injury or Symptom Onset Date (Date)When did your symptoms or injury first begin?
- Injury Description (Paragraph)Briefly explain how the injury occurred (e.g., sports accident, gradual onset, motor vehicle crash).
- Pain Severity Rating (Linear scale)Rate your current pain level on a scale from 1 (minimal pain) to 10 (severe pain).
- Aggravating Activities (Paragraph)What specific movements, activities, or positions make your pain or condition worse?
- Prior Treatment Status (Multiple choice)Have you received previous treatment for this condition (e.g., chiropractic, injections, physical therapy)?
- Current Medications (Paragraph)List any prescription medications, over-the-counter drugs, or supplements you are currently taking.
- Allergies (Short answer)List any known drug, latex, or environmental allergies.
- Medical Conditions Checklist (Checkboxes)Select any relevant past or current medical conditions that apply to you.
- Therapy Goals (Paragraph)What specific personal goals or functional milestones do you hope to achieve through physical therapy?
- Supporting Documents or Referrals (Paragraph)Please paste a link to your file (Google Drive, Dropbox, etc.) or describe the document you wish to attach.
FAQ
How do I use this Physical Therapy Evaluation Form template?
With Doc2Form, you can instantly turn this template into your own editable Google Form with a single click, allowing you to collect patient responses directly into your Google Drive.
Can I customize the questions on this form?
Yes! Once the template is loaded into your Google account, you have full freedom to add, remove, or modify any questions to match your clinic's specific documentation requirements.
Is this form template free to use?
Yes, this template is completely free to convert and deploy using Doc2Form and Google Forms.
Can patients fill this out on their mobile phones?
Yes, Google Forms are fully responsive and optimized for smartphones, tablets, and desktop computers.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.