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Client Intake Form for Injury Recovery Physical Therapy

I. Client Information

First Name

Last Name

Date of Birth

Gender

Phone Number

Email Address

Street Address

City/Suburb

State/Province

Postal/Zip Code

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Relationship

II. Injury Details

Date of Injury

Description of Injury.

How did the injury occur?

Accident

Sports

Repetitive strain

Other:

Have you sought medical treatment for this injury?

If yes, please provide details (e.g., the doctor’s name, diagnosis, treatments received).

Are you currently experiencing pain?

Please rate your current pain level on a scale of 0-10 (0 = no pain, 10 = worst pain imaginable)

Location of pain.

Type of pain. (Check all that apply)

Sharp

Dull

Throbbing

Constant

Intermittent

Other:

Are there any activities that worsen or alleviate the pain?

III. Medical History

Do you have any pre-existing medical conditions?

If yes, please specify.

Are you currently taking any medications?

If yes, please list.

Do you have any allergies (e.g., medications, latex, etc.)?

If yes, please specify.

Have you had any previous surgeries?

If yes, please provide details.

Do you have a history of chronic pain or recurring injuries?

If yes, please explain.

IV. Lifestyle and Activity Level

What is your occupation?

Does your job involve physical labor?

How would you describe your activity level?

Sedentary

Lightly Active

Moderately Active

Very Active

Do you participate in sports or recreational activities?

If yes, please specify.

Are there any specific goals you have for your recovery?

Return to sports

Improve mobility

Reduce pain

Other:

V. Therapy Suitability Assessment

Have you previously undergone physical therapy?

If yes, please describe the therapies and outcomes.

Are you open to trying the following therapies? (Check all that apply)

Manual Therapy: hands-on techniques like joint mobilization or massage (e.g., joint mobilization, soft tissue massage)

Exercise Therapy: stretching, strengthening, and balance exercises (e.g., stretching, strengthening, balance exercises)

Heat/Cold Therapy: for pain relief and inflammation reduction

Electrical Stimulation: Techniques like TENS or EMS for pain management and muscle activation

Ultrasound Therapy: uses sound waves to promote healing

Dry Needling: targets trigger points to relieve muscle tension

Aquatic Therapy: low-impact exercises in water for joint-friendly rehabilitation

Pilates or Yoga-Based Therapy: focuses on flexibility, core strength, and mindfulness

Postural Training: corrects alignment issues to prevent future injuries

Gait Training: improves walking patterns for mobility and balance

Other:

Are there any therapies you would prefer to avoid?

Do you have any concerns or fears about physical therapy?

VI. Physical Limitations and Preferences

Do you have any limitations in movement or mobility?

If yes, please describe.

Are you comfortable with hands-on therapy?

Do you have access to equipment for home exercises (e.g., resistance bands, weights)?

How much time can you commit to therapy sessions per week?

1 session

2-3 sessions

4+ sessions

VII. Additional Information

Is there anything else you would like us to know about your injury, health, or recovery goals?

VIII. Consent and Agreement

I understand that the information provided will be used to create a personalized physical therapy plan.

I consent to the proposed therapies and agree to communicate any concerns or changes in my condition.

Signature

Client Intake Form Insights

Please remove this client intake form insights section before publishing.


Important Notes:

  • This form is intended for informational purposes only and does not constitute medical advice.
  • Please consult with your physician before starting any new treatment.
  • All information provided will be kept confidential.

This comprehensive form will help you gather necessary information and determine the best course of treatment for each client. Remember to review the form with the client and address any questions or concerns they may have.


The Client Intake Form for Injury Recovery Physical Therapy is a critical tool for physical therapists to gather comprehensive information about a client’s injury, medical history, lifestyle, and preferences. Below is a detailed breakdown of the form’s sections, their purpose, and the insights they provide:


1. Client Information

Purpose: To establish basic demographic and contact details for communication and record-keeping.


Insights:

  • Helps personalize the therapy experience.
  • Ensures the therapist can reach the client or their emergency contact if needed.
  • Provides context for age- or gender-specific considerations in treatment planning.

2. Injury Details

Purpose: To understand the nature, cause, and current status of the injury.


Insights:

  • Date of Injury: Helps determine the stage of recovery (acute, subacute, or chronic).
  • Description of Injury: Provides clarity on the affected area and severity.
  • Pain Levels and Characteristics: Guides the therapist in selecting pain management strategies.
  • Activities Affecting Pain: Identifies triggers or alleviating factors, which can inform therapy modifications.

3. Medical History

Purpose: To identify pre-existing conditions, medications, allergies, and past surgeries that may impact therapy.


Insights:

  • Pre-existing Conditions: Conditions like diabetes or arthritis may influence recovery timelines or therapy choices.
  • Medications: Certain medications (e.g., blood thinners) may contraindicate specific therapies like dry needling.
  • Allergies: Ensures no allergic reactions to materials (e.g., latex) or therapies.
  • Surgical History: Past surgeries may indicate areas of weakness or scar tissue that need attention.

4. Lifestyle and Activity Level

Purpose: To assess the client’s daily activities, occupation, and physical demands.


Insights:

  • Occupation: Determines if the job involves physical strain, which may require ergonomic adjustments.
  • Activity Level: Helps tailor exercises to the client’s fitness level.
  • Sports/Recreational Activities: Identifies specific goals (e.g., returning to a sport) and potential risk factors.
  • Recovery Goals: Aligns therapy with the client’s expectations (e.g., pain relief, improved mobility, or athletic performance).

5. Therapy Suitability Assessment

Purpose: To gauge the client’s openness to different therapies and identify preferences or concerns.


Insights:

  • Previous Therapy Experience: Reveals what has or hasn’t worked in the past.
  • Therapy Preferences: Helps the therapist prioritize treatments the client is comfortable with.
  • Therapies to Avoid: Identifies contraindications or personal aversions (e.g., fear of needles for dry needling).
  • Concerns About Therapy: Addresses fears or misconceptions, ensuring the client feels safe and informed.

6. Physical Limitations and Preferences

Purpose: To understand the client’s current physical capabilities and comfort levels.


Insights:

  • Movement Limitations: Guides the selection of appropriate exercises and modifications.
  • Comfort with Hands-On Therapy: Determines if manual therapy is suitable or if alternative approaches are needed.
  • Access to Equipment: Informs the design of home exercise programs based on available resources.
  • Time Commitment: Helps create a realistic therapy schedule that fits the client’s lifestyle.

7. Additional Information

Purpose: To capture any other relevant details not covered in previous sections.


Insights:

  • Provides a space for the client to share unique concerns, goals, or expectations.
  • Ensures the therapist has a holistic understanding of the client’s needs.

8. Consent and Agreement

Purpose: To formalize the client’s consent for therapy and acknowledge their understanding of the process.


Insights:

  • Establishes trust and transparency between the client and therapist.
  • Ensures the client is committed to participating actively in their recovery.

Key Benefits of the Form

  1. Personalized Treatment Plans: By gathering detailed information, the therapist can design a recovery plan tailored to the client’s specific needs, goals, and preferences.
  2. Risk Mitigation: Identifying medical history, allergies, and contraindications helps avoid potential complications during therapy.
  3. Client-Centered Care: Understanding the client’s lifestyle, activity level, and preferences ensures the therapy is practical and aligned with their daily life.
  4. Improved Communication: The form encourages clients to share their concerns and expectations, fostering a collaborative relationship with the therapist.
  5. Efficient Progress Tracking: Baseline information allows the therapist to measure progress and adjust the plan as needed.

Conclusion

This intake form is a comprehensive tool that ensures the therapist has all the necessary information to provide safe, effective, and personalized care. It also empowers clients to actively participate in their recovery by expressing their preferences and concerns. By addressing physical, emotional, and lifestyle factors, the form lays the foundation for a successful rehabilitation journey.


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