Physical Therapy Intake Form

Physical Therapy Intake Form for India

Physical Therapy Intake Form Template for India

A comprehensive medical intake and consent document designed for physical therapy practices in India, compliant with the Clinical Establishments Act and relevant healthcare regulations. This document serves as the initial patient assessment tool, collecting vital medical history, current condition details, and necessary authorizations for treatment. It includes sections for patient demographics, medical background, current symptoms, pain assessment, and required legal consents, while incorporating specific requirements under Indian healthcare law for patient documentation and privacy protection.

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What is a Physical Therapy Intake Form?

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.

What sections should be included in a Physical Therapy Intake Form?

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

What sections are optional to include in a Physical Therapy Intake Form?

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

What schedules should be included in a Physical Therapy Intake Form?

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) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents

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Massage Therapy Consultation Form

An Indian-compliant massage therapy intake form combining medical screening, client consent, and liability provisions under Indian healthcare regulations.

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Download a Standard Physical Therapy Intake Form

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What is a Physical Therapy Intake Form?

What sections should be included in a Physical Therapy Intake Form?

What sections are optional to include in a Physical Therapy Intake Form?

What schedules should be included in a Physical Therapy Intake Form?

Authors

Alex Denne

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