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
Date of Injury
Description of Injury.
How did the injury occur?
Accident
Sports
Repetitive strain
Other:
Have you sought medical treatment for this injury?
Are you currently experiencing pain?
Do you have any pre-existing medical conditions?
Are you currently taking any medications?
Do you have any allergies (e.g., medications, latex, etc.)?
Have you had any previous surgeries?
Do you have a history of chronic pain or recurring injuries?
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?
Are there any specific goals you have for your recovery?
Return to sports
Improve mobility
Reduce pain
Other:
Have you previously undergone physical therapy?
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?
Do you have any limitations in movement or mobility?
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
Is there anything else you would like us to know about your injury, health, or recovery goals?
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 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:
2. Injury Details
Purpose: To understand the nature, cause, and current status of the injury.
Insights:
3. Medical History
Purpose: To identify pre-existing conditions, medications, allergies, and past surgeries that may impact therapy.
Insights:
4. Lifestyle and Activity Level
Purpose: To assess the client’s daily activities, occupation, and physical demands.
Insights:
5. Therapy Suitability Assessment
Purpose: To gauge the client’s openness to different therapies and identify preferences or concerns.
Insights:
6. Physical Limitations and Preferences
Purpose: To understand the client’s current physical capabilities and comfort levels.
Insights:
7. Additional Information
Purpose: To capture any other relevant details not covered in previous sections.
Insights:
8. Consent and Agreement
Purpose: To formalize the client’s consent for therapy and acknowledge their understanding of the process.
Insights:
Key Benefits of the Form
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.