Physical Therapy Intake Form

Physical Therapy Intake Form Template for India

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Key Requirements PROMPT example:

"I need a Physical Therapy Intake Form for my sports medicine clinic in Mumbai that includes detailed athletic injury assessment sections and is compliant with Indian healthcare regulations, with extra emphasis on consent forms for high-intensity rehabilitation procedures."

Document background

The Physical Therapy Intake Form is a crucial document used at the commencement of physical therapy services in India. It serves as both a clinical and legal document, designed to comply with the Clinical Establishments (Registration and Regulation) Act, 2010, and other relevant healthcare regulations. This form is essential for collecting comprehensive patient information, including medical history, current symptoms, and necessary consents for treatment. It helps physical therapists develop appropriate treatment plans while maintaining proper documentation required by Indian law. The form should be completed prior to initiating physical therapy services and updated as needed throughout the course of treatment. It also includes provisions for insurance billing and privacy protection in accordance with Indian healthcare standards.

Suggested Sections

1. Patient Information: Basic demographic details including name, date of birth, contact information, emergency contacts, and insurance details

2. Medical History: Comprehensive medical history including past surgeries, medications, allergies, and chronic conditions

3. Current Condition: Details about the presenting condition, including onset, symptoms, pain assessment, and current limitations

4. Lifestyle Assessment: Information about occupation, daily activities, exercise habits, and lifestyle factors affecting condition

5. Pain Assessment: Detailed pain evaluation including location, intensity, type, and aggravating/relieving factors

6. Consent for Treatment: Legal authorization for physical therapy treatment and acknowledgment of risks

7. Financial Agreement: Payment terms, insurance billing authorization, and financial responsibility acknowledgment

8. Privacy Notice Acknowledgment: Confirmation of receipt of privacy practices and consent for information sharing

Optional Sections

1. Workers' Compensation Information: Additional section for cases involving workplace injuries and workers' compensation claims

2. Sports/Athletic History: Detailed sports participation history for patients seeking sports-related physical therapy

3. Post-Surgical Protocol: Specific section for patients recovering from surgery, including surgeon's protocol

4. Pediatric Assessment: Additional developmental and medical history for pediatric patients

5. Pregnancy Considerations: Special considerations and precautions for pregnant patients

6. Fall Risk Assessment: Additional screening for elderly patients or those with balance issues

Suggested Schedules

1. Pain Diagram: Body diagram for marking pain locations and types

2. Functional Assessment Scale: Standardized scale for measuring functional limitations and capabilities

3. Exercise Log Template: Template for tracking prescribed exercises and progress

4. Insurance Information Form: Detailed insurance information and coverage verification form

Authors

Alex Denne

Head of Growth (Open Source Law) @ tiktok��˰� | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

Relevant legal definitions

Clauses

Relevant Industries

Healthcare

Medical Services

Allied Health

Rehabilitation Services

Sports Medicine

Insurance

Wellness and Fitness

Relevant Teams

Clinical Operations

Patient Administration

Medical Records

Compliance and Legal

Insurance and Billing

Quality Assurance

Patient Care

Front Office

Rehabilitation Services

Relevant Roles

Physical Therapist

Physiotherapy Assistant

Clinical Director

Healthcare Administrator

Medical Records Officer

Insurance Coordinator

Rehabilitation Specialist

Sports Medicine Specialist

Compliance Officer

Patient Care Coordinator

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