Book More
Patients

Turn Patient Interest Into Appointments
With Personalized Pre-Screening Plans.

Secure More Patients With Automated Pre-Screening Plans Sent in Minutes

Build a strong patient roster
Generate more appointments
Boost completed patient treatments

Give Patients Instant Access to a Pre-Screening Assessment

Automated Report Includes...
Clinic Summary
Physical Therapist(s) Service Overview
Treatment Type, Schedule and Plan
Calendar Booking Portal for Quick Access
...and more!

Sent in Minutes!

Clinic Info

First Name

Last Name

Phone *

Email *

Clinic Name

Patient Profile

Patient First Name (Demo Name)

Patient Last Name (Demo Name)

Patient Needs

What brings you to physical therapy?

Pain or discomfort

Injury or surgical recovery

Stiffness or limited mobility

Balance, weakness, or movement difficulties

Which body area is primarily affected?

Neck, shoulders, or arms

Back or spine

Hips, knees, or legs

Ankles, feet, or multiple areas

How long have you experienced these concerns?

Less than 2 weeks

2–6 weeks

1–6 months

More than 6 months

Overview

How did your concern begin?

Sudden injury or accident

Gradually developed over time

Following surgery or a medical procedure

Unsure or another circumstance

Which everyday activities are most affected?

Walking, standing, or climbing stairs

Sitting, sleeping, or resting comfortably

Working or performing household activities

Exercising, sports, or recreational activities

How much is this affecting your daily activities?

Mildly — I perform most activities normally

Moderately — Some activities are difficult

Significantly — Many activities are limited

Severely — I struggle with basic daily activities

Treatment Planning

What is your most important goal?

Reduce pain or discomfort

Improve movement, strength, or flexibility

Return to normal daily activities

Recover from an injury or surgery

Have you received professional care for this concern?

No, I have not sought care

Yes, from a physician or specialist

Yes, I previously received physical therapy

Yes, I am currently receiving treatment

Has a healthcare professional recommended physical therapy?

Yes, I have a referral

Yes, but I do not have a written referral

No, I am exploring physical therapy myself

I am unsure whether I need a referral

Care Planning

What would you most like to understand about your condition or care?

What may be contributing to my difficulties

How physical therapy may help me

How long improvement or recovery may take

What the evaluation and treatment process involves

Are you currently experiencing any of the following?

New or worsening numbness or weakness

Sudden loss of bladder or bowel control

Chest pain or difficulty breathing

None of the above

When would you like to schedule an initial evaluation?

As soon as possible

Within the next 7 days

Within the next 2–4 weeks

I would like more information before scheduling

End

Next

All Rights Reserved 2026 - The INfallible Business Systems