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Physical Therapy Progress & Experience Evaluation

Tracks a patient's pain, functional ability, home exercise adherence, and satisfaction with their physical therapy plan of care, with an AI follow-up that digs into what's really getting in the way of progress. Built for outpatient PT clinics running periodic check-ins or discharge reviews.

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Sample questions

A preview of what’s in the template. Every question is editable before you launch.

13 questions · ~7 min
Q01
Message

Thanks for taking a few minutes to check in on your physical therapy. Your answers help your care team adjust your plan and help us improve. This takes about 4-5 minutes and there are no wrong answers.

Q02
Multiple ChoiceRequired

What body area or condition are you currently receiving physical therapy for?

  • Low back
  • Neck or upper back
  • Shoulder
  • Knee
  • Hip
  • Ankle or foot
  • Wrist or hand
  • Post-surgical recovery
  • Balance or fall prevention
Q03
Opinion ScaleRequired

Right now, how would you rate your pain?

Scale: 0 – 10
Min:No painMax:Worst pain imaginable
Q04
MatrixRequired

In the last 7 days, how much difficulty have you had with each of the following?

6 rows × 5 columns
  • Walking short distances
  • Climbing stairs
  • Getting up from a chair or bed
  • Reaching overhead
  • Lifting or carrying objects
  • +1 more
Columns: No difficulty · Slight difficulty · Moderate difficulty · Severe difficulty · Unable to do
Q05
Opinion ScaleRequired

How much progress do you feel you've made toward the personal goals you set with your therapist?

Scale: 1 – 7
Min:No progress at allMax:Fully achieved my goals
Q06
Multiple ChoiceRequired

In the past 7 days, on how many days did you complete your prescribed home exercises?

  • 0 days
  • 1-2 days
  • 3-4 days
  • 5-6 days
  • 7 days (every day)
Q07
Multiple Choice

What has made it hardest to keep up with your home exercises? Select all that apply.

  • Exercises caused too much pain
  • Not enough time
  • Forgot to do them
  • Instructions weren't clear
  • Not sure they're helping
  • Lack of motivation
Q08
Rating ScaleRequired

How clearly has your therapist explained your condition and how to do your exercises correctly?

Range: 1 – 5
Min:Not clear at allMax:Extremely clear
Q09
AI Interview

Explore the gap between the patient's reported pain/functional difficulty and their sense of progress toward goals. If they reported low home-exercise adherence or specific barriers, probe concretely which exercises they skip, why, and whether pain during exercise is a factor versus time or motivation. If they report high adherence but low progress, probe whether the exercises feel matched to their goals or need to be adjusted. Anchor on specific recent sessions rather than general impressions.

Q10
Opinion ScaleRequired

How likely are you to recommend this physical therapy clinic to a friend or family member?

Scale: 0 – 10
Min:Not at all likelyMax:Extremely likely
Q11
Multiple Choice

What is your age range?

  • Under 18
  • 18-29
  • 30-44
  • 45-59
  • 60-74
  • 75 or older
  • Prefer not to say
Q12
Multiple Choice

How do you describe your gender?

  • Woman
  • Man
  • Non-binary
  • Prefer to self-describe
  • Prefer not to say
Q13
Message

Thank you for sharing this update. Your responses go directly to your care team to help fine-tune your treatment plan and are also used, in aggregate, to improve how we support patients like you.

What’s included

  • AI follow-ups

    Adaptive probes on open-ended answers that pull out detail a static form would miss.

  • Attention checks

    Built-in safeguards against rushed answers and low-quality respondents.

  • AI-drafted copy

    Wording, ordering, and branching written by the AI — tuned to your research goal.

  • Auto report

    Themes, quotes, and a plain-English summary write themselves once responses come in.

How it compares

We reviewed the closest templates from other survey tools. Here’s what they do well — and where this template goes further.

Why this template

  • Goes beyond static pain/function ratings with an AI follow-up interview specifically designed to dig into what's really blocking progress, not just capture a score
  • Combines a pain rating, a matrix of functional difficulty items, home exercise adherence tracking, and reasons for non-adherence in one flow rather than a single generic evaluation form
  • Includes clinician-relevant clarity questions (how well the therapist explained the condition and exercises) alongside outcome and satisfaction/recommendation measures
  • Opens and closes with clear chat messages framing the check-in and confirming responses go to the patient's care team, which builds trust and context missing from plain form fields

Jotform

Physical Therapy Evaluation Form Template

A standard fillable form template for capturing physical therapy evaluation details, built on Jotform's drag-and-drop form builder. It's fielding-ready out of the box and easy to customize with their editor, but it's a static field-based form rather than a conversational or adaptive survey. No mechanism to probe deeper into a patient's specific barriers to progress.

What it does well

  • Fielding-ready template usable immediately
  • Easy drag-and-drop customization within Jotform's ecosystem
  • Likely integrates with Jotform's broader form/e-signature/workflow tools

Where it falls short

  • Static form fields only — no adaptive AI follow-up to explore why a patient's pain or function isn't improving
  • No automated quality scoring of individual responses
  • No voice AI interview option for patients who prefer speaking over typing

SurveySparrow

Physical Therapy Evaluation Form Template

A conversational-style survey template aimed at healthcare use cases, which fits the same audience as this template. It offers a more engaging one-question-at-a-time format than a plain form, but its 'conversational' feel is templated and scripted rather than a true adaptive interview that reacts to what the patient says.

What it does well

  • Conversational, one-at-a-time UI likely improves completion rates versus a dense form
  • Positioned specifically for healthcare templates, suggesting relevant field types
  • Fielding-ready template for quick deployment

Where it falls short

  • No genuine adaptive AI questioning — flow is pre-scripted rather than dynamically probing individual answers
  • No per-response automated quality scoring reported
  • No published methodology for how follow-up questions (if any) are generated

Typeform

Physical Therapy Evaluation Form Template

Typeform's well-known conversational form format applied to a physical therapy evaluation, offering a polished, mobile-friendly respondent experience. It's a strong fielding-ready template, but like other form builders it lacks true adaptive branching driven by an AI reading and reacting to open-ended answers in real time.

What it does well

  • Polished, mobile-friendly conversational interface
  • Fielding-ready template within a widely used survey platform
  • Logic-based branching for basic conditional flows

Where it falls short

  • No AI-driven follow-up interview that adapts based on the substance of a patient's answers
  • No automated per-response quality scoring
  • No voice AI interview or guided screen-share task option

Ready to launch?

Open this template in the editor. Every part is yours to change before the first respondent sees it.

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