Client Intake Form Template for Rehabilitation & Corrective Exercise

Use in FirstRep form

Personal Information

Collecting basic personal information helps establish a rapport and ensures proper communication.

Aa Full Name *

John Doe

D Date of Birth *

Aa Contact Number *

123-456-7890

Aa Email Address *

[email protected]

Medical History

Understanding your medical history is crucial for safe rehabilitation and corrective exercise.

... Previous Injuries *

List any previous injuries...

... Surgeries *

List any surgeries you've had...

... Chronic Conditions

List any chronic conditions...

... Current Medications

List any medications you're currently taking...

Injury Details

Specific details about your injury will guide the rehabilitation process.

v Injury Type *

D Date of Injury *

Y/N Physical Therapy Completed *

... Rehabilitation Goals *

What are your goals for rehabilitation?

Current Physical Activity

Assessing your current activity level will help tailor the program to your needs.

v Activity Level *

vv Preferred Exercise Types

# Exercise Frequency *

Times per week

Client Concerns

Addressing any concerns helps build trust and ensures a focused approach to rehabilitation.

1-10 Fear of Re-injury *

1-10 Frustration with Progress *

... Additional Concerns

Please list any other concerns...

Documentation and Communication

Understanding the documentation process and communication with healthcare professionals is vital.

Aa PT/Doctor Contact Information *

Name & Contact

v Documentation Preferences *

Why Use This Template

Comprehensive Understanding

Gathering detailed client information helps create a personalized rehabilitation plan.

Builds Trust

A thorough intake process fosters trust and open communication between you and your clients.

How to Use

Distribute the form to clients before their first session to maximize consultation time.

Review the completed form with the client to clarify any concerns or questions.

Customization Tips

Adjust the language to fit your personal coaching style.
Add specific fields to address unique client needs.
Incorporate visual elements to enhance engagement.

Build and send rehabilitation & corrective exercise templates digitally with FirstRep. Free for up to 3 clients.

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Frequently Asked Questions

What if my client is unsure about their medical history?

Encourage them to consult their doctor for accurate information and to ensure safe participation.

How do I handle client fears about re-injury?

Provide education on safe practices and gradual progression to build confidence.