Use our readymade template to create this Google form. Customize it further using our form builder.
Create your intake form
- Use prebuilt template to create a HIPAA compliant online physiotherapy intake form
- Collect patient, demography, emergency contact details, medical history
- Collect details about the primary concern, injury, pain levels, and physical limitations
- Capture lifestyle information, allergies, and insurance details
- Get signatures for consent for treatment, notice of privacy practices, use of PHI
Collect responses from your patients
|Emergency Contact Phone
|What is your primary reason for your physiotherapy consultation?
|Have you ever had physical therapy for this problem?
|What are your main complaints?
|If you have pain, please rate your level of pain over the last 24 hours
|Pain at best
|Since the problem started, is it:
|Do you eat a well-balanced diet?
- Pre-populate patient details from your booking system to reduce errors
- Send an email invitation with a secure link for patients to complete their intake
- Allow patients to save their progress and complete their form at a later time
- Set up an email template and send invitation emails to multiple patients with ease
- Send an email to the patients with a copy of their response when they submit the form
Track patient responses in Google Sheets
- Export patient responses to Google Sheets for easy record-keeping
- Create a custom workflow and manage your patient intake efficiently
- Use pre-built reports to easily keep track of patient progress over time
- Receive a copy of the response by email when a patient submits the intake form
- Use data in Google Sheets to integrate with EHR systems for seamless data transfer
|Emergency Contact Phone:
|What is your primary reason for your physiotherapy consultation?:
|Have you ever had physical therapy for this problem?:
|What are your main complaints?:
|If you have pain, please rate your level of pain over the last 24 hours:
|Pain at best:
|Since the problem started, is it::
|Do you eat a well-balanced diet?:
- Create a HIPAA compliant intake form to safely collect, store and access patient responses
- Mark fields as Protected Health Information to secure sensitive data and limit access to PHI
- Mask PHI fields when exporting form responses to Google Sheets and sending them on email
- Pre-populate patient details in intake forms by creating secure prefill links without exposing PHI
- Limit access to patient data only for authorized personnel and minimize risk of data breaches
These reviews are reproduced without modification from Google Workspace Marketplace.
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July 23, 2023
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February 16, 2024
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