Intake form templates, field by field

Why an intake form cannot be a noun swap

The four forms here look similar in shape and differ almost entirely in their middle. A physiotherapy intake asks what the injury is, how it happened, what makes it worse and where the pain sits on a scale. A chiropractic intake asks about spinal history, previous imaging and the red flags that rule treatment out. A massage intake asks about pressure preference, areas to avoid and the contraindications that change the session. A psychology intake asks about the presenting concern, mood, risk and who else is involved in care. Copying one discipline's questions into another produces a form that collects the wrong history.

Consent and privacy sit inside the form, not beside it

Each of these forms carries a signature field so the client can consent before the first session rather than at the desk. That is why all four use the classic layout, since a signature component only exists there. Each also puts a plain paragraph above the health questions saying what is collected, who reads it and how long it is kept, because a classic field's description is not shown to the person filling it in. None of them collects a Medicare number or card details, which belong in a practice management system rather than an intake form.

Adapting one to your practice

Start from the discipline closest to yours, then change three things. First the history section, which is the part that carries your clinical reasoning. Second the consent wording, which should match what your professional board and your insurer expect. Third the referral question, since practices that take GP referrals need the referrer's details captured up front and practices that do not can drop the field. Every page lists each field in order with what it collects, so the edit is a matter of deletion and rewording rather than starting again.

Every page in this collection

• Chiropractic intake form with a spine history grid

  A chiropractor examining a lower back needs to know what the neck, the mid back and the jaw have been doing for the last three months, and asking that one region at a time takes the whole appointment. This seventeen field form puts eight regions in a single grid and screens for the conditions that change the plan.

• Massage intake form that asks about pressure before the table

  A client lying face down with their eyes closed will almost never ask for lighter pressure or say that they would rather their feet were left alone. This fourteen field intake form asks both in advance, alongside a contraindication screen that adapts the technique rather than cancelling the booking.

• Physiotherapy intake form built around one injury

  A physiotherapist has about forty minutes and needs a third of it to examine, so the history has to arrive before the patient does. This eighteen field intake form maps the region and side, the onset, the pain score and what aggravates it, then records which funding pathway is paying.

• Psychology intake form with the limits of confidentiality on it

  A first psychology session has fifty minutes and a person who has usually waited weeks for it, so the history should not eat the first twenty. This twenty field intake form takes the referral pathway, a ten item distress baseline and the supports already in place, and states the limits of confidentiality above the signature.