Physical therapy intake form: know the problem before day one

Patients tell the whole story to the receptionist, then again to you. I would rather they tell it once, in their own words, before the first session. The form keeps it short and the answers sortable.

The problem

Where it hurts, when it started and how. These three answers shape the first exam. A date field gives you a rough timeline without a long chat.

How bad it is

Two pain scores, now and at its worst this week, plus what makes it worse. The scores give you a baseline to compare against later.

Life and goals

What the patient cannot do and wants to do again, plus what they tried. Goals tell you what to aim for, so a plan has a point.

Safety

Whether a doctor sent them, and a short list of flags before exercise. Check these first.

Who fills it and who reads it

Patients answer, and the therapist reads before the visit. See more forms for clinics and forms for therapists.

A patient's AI would ask "Where is the problem?" Then "How bad is the pain right now, from 0 to 10?" Then "What can you not do that you want to do?" It lists all answers and sends only after a yes. See agent-fillable forms.

One tip

Read daily_limits aloud at the start of the session. Check your local privacy rules before collecting health data. This is a form, not medical advice. A patient intake form covers general details, and an online consultation form fits remote follow-ups.

Questions

Can I use it for speech or occupational therapy?

Yes, with edits. Change the problem areas and triggers to match your field, and keep the questions about goals, earlier treatment and safety flags.

What does the pain score tell me?

It is the patient's own number for pain now and at its worst this week. Compare it at each visit. Treat it as a conversation starter, not a diagnosis.

Can the patient use their AI to answer?

Yes. The patient pastes the agent prompt into their chat, answers the AI's questions, reviews all answers and sends them after saying yes.

Or paste the JSON

Give this to your AI. It needs the AI Form API MCP server or an API key. It makes the form and sends you the link.

text

Create this form with the AI Form API create_form tool (or POST https://aiformapi.com/v1/forms with my API key). Then reply with the public_url.

{
  "title": "Tell us about your pain or injury",
  "description": "Answer before your first session so we can focus on what matters to you. Skip anything you are unsure about.",
  "fields": [
    {
      "id": "patient_name",
      "label": "Your full name",
      "type": "short_text",
      "required": true,
      "max_length": 150
    },
    {
      "id": "birth_date",
      "label": "Date of birth",
      "type": "date",
      "required": true
    },
    {
      "id": "contact_phone",
      "label": "Phone",
      "type": "phone",
      "required": true
    },
    {
      "id": "problem_areas",
      "label": "Where is the problem?",
      "type": "multi_choice",
      "required": true,
      "options": [
        "Neck",
        "Shoulder",
        "Elbow or wrist",
        "Back",
        "Hip",
        "Knee",
        "Ankle or foot",
        "Whole body"
      ],
      "min": 1
    },
    {
      "id": "problem_start",
      "label": "Roughly when did it start?",
      "type": "date"
    },
    {
      "id": "how_it_started",
      "label": "How did it start?",
      "type": "single_choice",
      "options": [
        "A sudden injury",
        "Slowly over time",
        "After surgery",
        "After a fall",
        "From sport or exercise",
        "I do not know"
      ]
    },
    {
      "id": "pain_now",
      "label": "Pain right now",
      "type": "rating",
      "help": "0 is no pain and 10 is the worst you can imagine.",
      "min": 0,
      "max": 10
    },
    {
      "id": "pain_worst_week",
      "label": "Pain at its worst this week",
      "type": "rating",
      "min": 0,
      "max": 10
    },
    {
      "id": "pain_triggers",
      "label": "What makes it worse?",
      "type": "multi_choice",
      "options": [
        "Sitting",
        "Standing",
        "Walking",
        "Lifting",
        "Sleeping",
        "Stairs",
        "Exercise"
      ]
    },
    {
      "id": "daily_limits",
      "label": "What can you not do that you want to do?",
      "type": "long_text",
      "max_length": 1000
    },
    {
      "id": "treatment_so_far",
      "label": "What have you tried so far?",
      "type": "long_text",
      "max_length": 1000
    },
    {
      "id": "doctor_referral",
      "label": "Did a doctor send you?",
      "type": "single_choice",
      "options": [
        "Yes",
        "No",
        "I am not sure"
      ]
    },
    {
      "id": "exercise_flags",
      "label": "Does any of this apply before we start exercises?",
      "type": "multi_choice",
      "options": [
        "Heart condition",
        "Osteoporosis",
        "Pregnancy",
        "Recent surgery",
        "Dizziness",
        "None of these"
      ]
    }
  ]
}

Or call the API

bash

curl -X POST https://aiformapi.com/v1/forms \
  -H "Authorization: Bearer $AIFORMAPI_KEY" \
  -H "Content-Type: application/json" \
  -d '{"title":"Tell us about your pain or injury","description":"Answer before your first session so we can focus on what matters to you. Skip anything you are unsure about.","fields":[{"id":"patient_name","label":"Your full name","type":"short_text","required":true,"max_length":150},{"id":"birth_date","label":"Date of birth","type":"date","required":true},{"id":"contact_phone","label":"Phone","type":"phone","required":true},{"id":"problem_areas","label":"Where is the problem?","type":"multi_choice","required":true,"options":["Neck","Shoulder","Elbow or wrist","Back","Hip","Knee","Ankle or foot","Whole body"],"min":1},{"id":"problem_start","label":"Roughly when did it start?","type":"date"},{"id":"how_it_started","label":"How did it start?","type":"single_choice","options":["A sudden injury","Slowly over time","After surgery","After a fall","From sport or exercise","I do not know"]},{"id":"pain_now","label":"Pain right now","type":"rating","help":"0 is no pain and 10 is the worst you can imagine.","min":0,"max":10},{"id":"pain_worst_week","label":"Pain at its worst this week","type":"rating","min":0,"max":10},{"id":"pain_triggers","label":"What makes it worse?","type":"multi_choice","options":["Sitting","Standing","Walking","Lifting","Sleeping","Stairs","Exercise"]},{"id":"daily_limits","label":"What can you not do that you want to do?","type":"long_text","max_length":1000},{"id":"treatment_so_far","label":"What have you tried so far?","type":"long_text","max_length":1000},{"id":"doctor_referral","label":"Did a doctor send you?","type":"single_choice","options":["Yes","No","I am not sure"]},{"id":"exercise_flags","label":"Does any of this apply before we start exercises?","type":"multi_choice","options":["Heart condition","Osteoporosis","Pregnancy","Recent surgery","Dizziness","None of these"]}]}'

JSON definition

json

{
  "title": "Tell us about your pain or injury",
  "description": "Answer before your first session so we can focus on what matters to you. Skip anything you are unsure about.",
  "fields": [
    {
      "id": "patient_name",
      "label": "Your full name",
      "type": "short_text",
      "required": true,
      "max_length": 150
    },
    {
      "id": "birth_date",
      "label": "Date of birth",
      "type": "date",
      "required": true
    },
    {
      "id": "contact_phone",
      "label": "Phone",
      "type": "phone",
      "required": true
    },
    {
      "id": "problem_areas",
      "label": "Where is the problem?",
      "type": "multi_choice",
      "required": true,
      "options": [
        "Neck",
        "Shoulder",
        "Elbow or wrist",
        "Back",
        "Hip",
        "Knee",
        "Ankle or foot",
        "Whole body"
      ],
      "min": 1
    },
    {
      "id": "problem_start",
      "label": "Roughly when did it start?",
      "type": "date"
    },
    {
      "id": "how_it_started",
      "label": "How did it start?",
      "type": "single_choice",
      "options": [
        "A sudden injury",
        "Slowly over time",
        "After surgery",
        "After a fall",
        "From sport or exercise",
        "I do not know"
      ]
    },
    {
      "id": "pain_now",
      "label": "Pain right now",
      "type": "rating",
      "help": "0 is no pain and 10 is the worst you can imagine.",
      "min": 0,
      "max": 10
    },
    {
      "id": "pain_worst_week",
      "label": "Pain at its worst this week",
      "type": "rating",
      "min": 0,
      "max": 10
    },
    {
      "id": "pain_triggers",
      "label": "What makes it worse?",
      "type": "multi_choice",
      "options": [
        "Sitting",
        "Standing",
        "Walking",
        "Lifting",
        "Sleeping",
        "Stairs",
        "Exercise"
      ]
    },
    {
      "id": "daily_limits",
      "label": "What can you not do that you want to do?",
      "type": "long_text",
      "max_length": 1000
    },
    {
      "id": "treatment_so_far",
      "label": "What have you tried so far?",
      "type": "long_text",
      "max_length": 1000
    },
    {
      "id": "doctor_referral",
      "label": "Did a doctor send you?",
      "type": "single_choice",
      "options": [
        "Yes",
        "No",
        "I am not sure"
      ]
    },
    {
      "id": "exercise_flags",
      "label": "Does any of this apply before we start exercises?",
      "type": "multi_choice",
      "options": [
        "Heart condition",
        "Osteoporosis",
        "Pregnancy",
        "Recent surgery",
        "Dizziness",
        "None of these"
      ]
    }
  ]
}

A physical therapy intake form that starts with the real problem