About this template
This Physiotherapy Intake Google Form template helps clinics, physical therapists, and rehabilitation centers streamline new patient onboarding. Designed to capture essential medical history, insurance coverage, physical complaints, and specific treatment goals before the initial appointment, this form ensures clinicians have all the necessary background to prepare personalized rehabilitation plans.
The form collects critical data including contact information, occupation, physical measurements, insurance provider details, lifestyle factors, pregnancy or lactation status where relevant, and detailed pain assessments. Utilizing a structured layout, it helps practitioners quickly identify primary physical complaints, pain duration, and patient expectations.
Built for seamless digital access, patients can complete this questionnaire easily on any smartphone, tablet, or desktop computer before arriving at the clinic. By using Doc2Form to deploy this template directly into your Google Workspace, you eliminate paper clutter, reduce front-desk wait times, and ensure all patient records are securely organized in a linked Google Sheet for instant review.
Key features
- Streamline new patient onboarding before the first appointment
- Capture detailed pain scales, history, and physical complaints
- Collect complete health insurance and coverage information
- Fully responsive design for easy completion on mobile devices
- Automatically syncs all patient submissions to Google Sheets
Use cases
New patient registration at physical therapy and chiropractic clinics
Pre-screening for sports rehabilitation and injury recovery programs
Gathering insurance and medical background for outpatient wellness ce…
Gathering insurance and medical background for outpatient wellness centers
What this form collects
- Patient’s Full Name (Short answer)Enter your first and last name.
- Gender (Multiple choice)Select your gender identity.
- Date of Birth (Date)Enter your date of birth.
- Phone Number (Short answer)Enter the best phone number to reach you.
- Email Address (Short answer)Enter your email address for appointment confirmations.
- Home Address (Paragraph)Enter your street address, city, state, and ZIP code.
- Occupation / Job Title (Short answer)Describe your primary daily work activities.
- Weight (kg) (Short answer)Enter your approximate weight in kilograms.
- Height (in) (Short answer)Enter your height in inches.
- Insurance Status (Multiple choice)Select your current insurance coverage type.
- Insurance Company Name (Short answer)Provide the name of your insurance provider.
- Health Insurance / Policy Number (Short answer)Enter your member ID or policy number.
- Active Lifestyle Status (Multiple choice)Describe your general level of physical activity.
- Physical Activities List (Paragraph)List any sports, exercises, or hobbies you regularly participate in.
- Primary Physical Complaint (Paragraph)Describe the main issue or injury bringing you in today.
- Secondary Complaint (Paragraph)List any other areas of discomfort or secondary pain.
- Current Pain Rating (Linear scale)Rate your current pain level from 1 (mild) to 10 (severe).
- Pain Duration (Multiple choice)How long have you been experiencing this pain?
- Are you currently pregnant? (Multiple choice)Select yes if applicable.
- Therapy Expectations (Paragraph)What do you hope to achieve through physiotherapy?
- Treatment Goals (Paragraph)List specific milestones or activities you want to return to (e.g., running, lifting grandchildren).
- Referral Source (Dropdown)How did you hear about our clinic?
FAQ
How do I customize this physiotherapy intake form?
Once you convert and open the template in Google Forms, you can easily add, remove, or edit questions, adjust your clinic branding, and modify required fields using the standard Google Forms editor.
Can patients fill this form out on their mobile phones?
Yes. Google Forms are fully responsive and work seamlessly on smartphones, tablets, and desktop computers without requiring any special apps.
Where do the patient responses go?
All submissions are automatically routed to a secure Google Sheet connected to your form, allowing your clinical team to review patient details instantly.
Can I add custom consent or waiver sections?
Yes, you can easily insert additional checkboxes or text sections for clinic policies, treatment consent, or HIPAA acknowledgments using the Google Forms editor.
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.