Client Intake Form for Tele-Physiotherapy
Date
I. Client Information
First Name
Last Name
Date of Birth
Gender
Contact Information
Street Address
Street Address Line 2
City
State/Province
Postal/Zip Code
Phone Number
Email Address
Emergency Contact
Full Name
Phone Number
Preferred Language
II. Medical History
Have you been diagnosed with any musculoskeletal conditions?
If yes, please specify
Do you have any chronic medical conditions (e.g., diabetes, heart disease, etc.)?
If yes, please specify
Are you currently taking any medications?
If yes, please list
Have you had any surgeries related to your musculoskeletal condition?
If yes, please specify
Do you have any allergies or sensitivities?
If yes, please specify
Have you experienced any recent injuries or accidents?
If yes, please describe
Are you currently receiving treatment from another healthcare provider?
If yes, please provide details
III. Current Symptoms and Functional Limitations
Please describe your primary symptoms (e.g., pain, stiffness, weakness)
Location of symptoms
Lower back
Shoulder
Knee
Other (Please specify):
On a scale of 1 to 10, how severe is your pain or discomfort? (With 0 being no pain and 10 being the worst pain imaginable)
How long have you been experiencing these symptoms?
Less than 1 week
1-4 weeks
1-6 months
Over 6 months
Are there any activities or movements that worsen your symptoms?
If yes, please provide details
Are there any activities or movements that improve your symptoms?
If yes, please describe
How do your symptoms affect your daily activities?
Walking
Sitting
Lifting
Other (Please specify):
IV. Lifestyle and Goals
What is your current level of physical activity?
Sedentary
Light activity
Moderate activity
High activity
Other (Please specify)
Do you engage in any specific sports or recreational activities?
If yes, please specify
What are your primary goals for tele-physiotherapy? (Select all that apply)
Reduce pain
Improve mobility
Increase strength
Enhance flexibility
Prevent future injuries
Return to sport/activity
Other (Please specify)
Do you have access to any exercise equipment at home (e.g., resistance bands, weights, yoga mat)?
If yes, please specify
V. Suitability for Tele-Physiotherapy
Do you have access to a reliable internet connection and a device with a camera (e.g., smartphone, tablet, computer)?
Are you comfortable using video conferencing tools?
Do you have a safe and private space to perform exercises during sessions?
Are there any barriers to participating in virtual sessions (e.g., language, technology, physical limitations)?
If yes, please describe
VI. Treatment Options and Preferences
Based on your condition, the following treatment options may be offered. Please indicate your comfort level with each
Treatment Option | Comfort Level Yes/No | Additional Notes | ||
|---|---|---|---|---|
A | B | C | ||
1 | Exercise Prescription | |||
2 | Stretching and Flexibility Training | |||
3 | Strengthening Exercises | |||
4 | Postural Correction | |||
5 | Pain Management Techniques | |||
6 | Manual Therapy (Self-Mobilization) | |||
7 | Ergonomic Advice | |||
8 | Education on Injury Prevention | |||
9 | Breathing and Relaxation Exercises |
Are there any specific treatments or techniques you would like to avoid?
If yes, please specify
VII. Consent and Agreement
I understand that tele-physiotherapy involves virtual assessment and treatment sessions, and I consent to participate.
I acknowledge that tele-physiotherapy has limitations, and in-person care may be required for certain conditions.
I agree to provide accurate information about my health and symptoms to ensure safe and effective treatment.
I understand that I can withdraw consent at any time.
Client Signature:
Form Template Insight
Form Template Insight
Please remove this form template insight sections before publishing.
Below is a detailed breakdown of the Client Intake Form for Tele-Physiotherapy, explaining the purpose and importance of each section and question. This form is designed to gather comprehensive information about the client’s condition, medical history, lifestyle, and preferences to ensure safe, effective, and personalized virtual physiotherapy sessions.
Section 1: Client Information
Purpose: To collect basic demographic and contact details for identification, communication, and emergency purposes.
- Full Name, Date of Birth, Gender: Helps personalize the treatment and ensure accurate record-keeping.
- Contact Information: Essential for scheduling sessions and sending reminders or follow-ups.
- Emergency Contact: Provides a safety net in case of unexpected issues during virtual sessions.
- Preferred Language: Ensures clear communication and avoids language barriers.
Section 2: Medical History
Purpose: To understand the client’s overall health, identify contraindications, and tailor treatments to their specific needs.
- Musculoskeletal Conditions: Identifies pre-existing issues that may influence treatment.
- Chronic Medical Conditions: Highlights comorbidities (e.g., diabetes, heart disease) that could affect exercise prescription or pain management.
- Medications: Some medications (e.g., blood thinners, painkillers) may impact treatment safety or effectiveness.
- Surgeries: Past surgeries may indicate areas of weakness or vulnerability.
- Allergies/Sensitivities: Ensures no treatments or advice conflict with the client’s health.
- Recent Injuries/Accidents: Provides context for current symptoms and guides assessment.
- Other Healthcare Providers: Helps coordinate care and avoid conflicting treatments.
Section 3: Current Symptoms and Functional Limitations
Purpose: To assess the client’s primary concerns, severity of symptoms, and how they impact daily life.
Primary Symptoms: Identifies the main issues (e.g., pain, stiffness, weakness) to address.
- Location of Symptoms: Pinpoints the affected area(s) for targeted treatment.
- Pain Severity: Quantifies pain levels to track progress over time.
- Duration of Symptoms: Helps determine whether the condition is acute or chronic.
- Aggravating/Alleviating Factors: Identifies triggers or activities that worsen/improve symptoms.
- Impact on Daily Activities: Assesses functional limitations to set realistic goals.
Section 4: Lifestyle and Goals
Purpose: To understand the client’s activity level, preferences, and rehabilitation goals.
- Physical Activity Level: Guides exercise intensity and progression.
- Sports/Recreational Activities: Tailors treatment to support the client’s hobbies or sports.
- Goals for Tele-Physiotherapy: Helps prioritize treatment outcomes (e.g., pain reduction, improved mobility).
- Access to Equipment: Determines what exercises can be prescribed based on available resources.
Section 5: Suitability for Tele-Physiotherapy
Purpose: To ensure the client is a good candidate for virtual sessions and has the necessary resources.
- Reliable Internet and Device: Confirms the client can participate in video sessions.
- Comfort with Technology: Assesses the client’s ability to use video conferencing tools.
- Safe and Private Space: Ensures the client can perform exercises without distractions or safety risks.
- Barriers to Participation: Identifies potential challenges (e.g., language, physical limitations) that may require accommodations.
Section 6: Treatment Options and Preferences
Purpose: To involve the client in decision-making and ensure treatments align with their comfort level and preferences.
- Comfort Level with Treatments: Assesses the client’s willingness to engage in specific therapies (e.g., exercise, manual therapy).
- Avoidance of Specific Treatments: Respects the client’s boundaries and preferences.
- Customization: Allows the physiotherapist to tailor the treatment plan to the client’s needs and preferences.
Section 7: Consent and Agreement
Purpose: To obtain informed consent and ensure the client understands the nature and limitations of tele-physiotherapy.
- Consent to Participate: Confirms the client’s agreement to engage in virtual sessions.
- Acknowledgment of Limitations: Ensures the client understands that tele-physiotherapy may not replace in-person care in all cases.
- Accuracy of Information: Encourages honesty to ensure safe and effective treatment.
- Withdrawal of Consent: Reassures the client that they can stop treatment at any time.
Key Insights and Benefits of the Form
- Comprehensive Assessment: The form gathers all necessary information to create a holistic understanding of the client’s condition, lifestyle, and goals.
- Personalized Treatment: By identifying the client’s preferences and limitations, the physiotherapist can design a tailored treatment plan.
- Safety and Suitability: The form ensures the client is a good candidate for tele-physiotherapy and identifies any potential risks or barriers.
- Client-Centered Care: Involving the client in decision-making (e.g., treatment preferences, goals) promotes engagement and adherence to the treatment plan.
- Legal and Ethical Compliance: The consent section ensures the client is fully informed and agrees to the terms of virtual care.
How This Form Enhances Tele-Physiotherapy
- Efficiency: Saves time during the initial assessment by collecting information in advance.
- Continuity of Care: Provides a detailed record for future reference or sharing with other healthcare providers.
- Improved Outcomes: By addressing the client’s unique needs and preferences, the form helps achieve better rehabilitation results.
- Client Empowerment: Encourages clients to take an active role in their treatment and recovery.
This form is a critical tool for delivering high-quality, client-centered tele-physiotherapy services while ensuring safety, suitability, and effectiveness.
To configure an element, select it on the form.