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Concierge Agent
Physical Therapy Intake Form Template
Intake forms lose 40% of PT patients. Automatically adjust question flow based on injury type, pain severity, and treatment history. Capture detailed functional assessments and prior therapy outcomes to help therapists prepare targeted treatment plans before the first session.
Complete histories
Better compliance
Faster treatment
Used 1,924+ times
What's inside this template
Start from this conversation and adapt it to your team — change any question, add your own logic, and connect the tools you already use.
Questions it always asks
The core fields every response captures.
Current pain level on 0-10 scale and pain location
Previous physical therapy experience and outcomes
How it adapts
Follow-ups that change based on what people say.
If patient reports back pain, ask about lifting mechanics and sitting tolerance
If surgery mentioned, collect surgical date and post-op restrictions
Where it routes people
Different paths for different answers.
Route acute injuries (under 6 weeks) to urgent care protocols
Direct post-surgical patients to specialized rehab questionnaire
Automations it can trigger
Actions that fire the moment a response comes in.
Send intake summary to assigned therapist 24 hours before appointment
Create patient file in EMR with collected assessment data
Schedule follow-up reminder based on injury severity level
SOC 2 Type II and ISO 27001:2022 certified. Responses are encrypted in transit and at rest, and you own your data. View our Trust Center.
How this AI template works
Patients answer initial questions about their condition, then the AI asks targeted follow-ups based on injury location and severity. The system gathers detailed pain patterns, functional limitations, and therapy history to create comprehensive intake records.
Getting started
- 1
Add your clinic information and therapist specialties
- 2
Configure pain scale ranges and functional assessment criteria
- 3
Set up routing rules for different injury types
- 4
Connect to your practice management system
Template Details
- Agent Type
- Concierge
- Category
- Healthcare intake & survey
- Role
- SalesOperations
- Industry
- Health & Wellness
- Business outcome
- Convert more leadsOperate more efficiently
- Job to be done
- Run client intake
- Journey stage
- Intake & qualification
- Integrations
- Email, Ehr, Calendar
- Times Used
- 1,924+
Forms collect fields. Conversations capture context.
Static forms force complex situations into rigid dropdowns. Perspective captures structured data and the reasoning behind it — so your team makes better decisions, faster.
The static form
yoursite.com/intake
Category *
Select...
Details
Describe your situation...
Submit
Result:Category: "Other"|Details: "It's complicated"
No context. No follow-up. No next step.
- Patients abandon lengthy PT intake forms after 5-10 minutes, providing incomplete injury histories that force therapists to spend appointment time re-gathering basic information.
- Static pain assessment dropdowns can't capture the nuanced descriptions therapists need, like 'sharp pain when reaching overhead but dull ache at rest.'
- Insurance verification sections are frequently left blank or filled incorrectly because patients don't understand what information their PT clinic actually needs.
The AI conversation
"Tell me more about the timeline — when did this start, and is there a deadline your team is working against?"
Extracted & structured automatically
Category
High-priority
Urgency
Deadline: 2 weeks
Sentiment
Frustrated but hopeful
Next step
Route to senior team
Triggered: Slack alert sent| CRM updated
Right team. Full context. Instant action.
- AI conversations guide patients through detailed pain assessments, capturing intensity, location, triggers, and functional impacts that inform precise treatment planning.
- Natural dialogue encourages patients to describe their complete injury timeline, including previous treatments, current medications, and lifestyle factors affecting recovery.
- Intelligent follow-up questions ensure insurance details, referral requirements, and prior authorization information are complete before the first visit.
What information should a physical therapy intake form collect?
Effective PT intake forms capture comprehensive injury history, detailed pain assessments, and functional limitations that impact daily activities. Essential elements include current symptom descriptions with pain scales, previous treatments and outcomes, medications affecting healing, and specific functional deficits. Insurance information, physician referrals, and prior authorization details prevent billing delays. The intake should document work restrictions, exercise tolerance, and recovery expectations to establish realistic treatment timelines and goals.
FAQ
Frequently Asked Questions
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Replace drop-off, poor qualification, and missing context with AI conversations that capture structured data and real understanding. Set up in minutes.
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