Physical Therapy Intake Form for Canada

Physical Therapy Intake Form Template for Canada

This document serves as a comprehensive patient intake form used by physical therapy practices in Canada, designed to comply with federal and provincial healthcare privacy laws, including PIPEDA and provincial health information acts. The form collects essential patient information, medical history, current condition details, and necessary consents for treatment while ensuring proper documentation as required by provincial physical therapy regulatory bodies. It facilitates the initial assessment process and establishes the foundation for the therapeutic relationship between the physical therapist and patient, while maintaining compliance with Canadian healthcare documentation standards.

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What is a Physical Therapy Intake Form?

The Physical Therapy Intake Form is a foundational document used during a patient's first visit to a physical therapy practice in Canada. This document is essential for collecting comprehensive patient information, including personal details, medical history, current symptoms, and informed consent for treatment. It must comply with Canadian federal privacy legislation (PIPEDA) and relevant provincial health information privacy acts. The form serves multiple purposes: establishing the patient-therapist relationship, documenting medical history and current conditions, ensuring informed consent, and creating a baseline for treatment planning. It is typically completed before the initial assessment and becomes part of the patient's permanent medical record, supporting continuity of care and legal compliance.

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

1. Patient Information: Basic demographic and contact information including name, date of birth, address, phone, email, and emergency contact details

2. Insurance Information: Details of primary and secondary insurance coverage, policy numbers, and claim information if applicable

3. Current Condition: Information about the presenting problem, including onset, cause, symptoms, and current pain levels

4. Medical History: General health history including previous injuries, surgeries, medications, and known medical conditions

5. Lifestyle & Occupation: Information about work, daily activities, and lifestyle factors that may impact treatment

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

7. Consent for Treatment: Legal authorization for physical therapy evaluation and treatment

8. Privacy Policy Acknowledgment: Patient acknowledgment of privacy practices and information sharing policies

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

1. Women's Health History: Additional section for practices focusing on women's health, including pregnancy and pelvic health history

2. Sports History: For sports medicine focused practices, detailed athletic history and activity levels

3. Previous Physical Therapy: Section detailing any previous physical therapy treatments and outcomes

4. Fall Risk Assessment: For practices treating elderly patients or those with balance issues

5. Pediatric Development History: For pediatric patients, including developmental milestones and birth history

6. Worker's Compensation Information: Additional details needed for work-related injuries and compensation claims

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

1. Privacy Policy: Detailed explanation of the clinic's privacy practices and patient rights

2. Payment Policy: Explanation of billing practices, insurance claims process, and payment expectations

3. Body Diagram: Anatomical diagram for patients to mark areas of pain or discomfort

4. Consent Forms: Detailed consent forms for specific treatments or procedures

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

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 | Serial Founder & Legal AI Author

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Rehabilitation Services

Sports Medicine

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Medical Records

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Relevant Roles

Physical Therapist

Clinic Manager

Administrative Coordinator

Medical Records Officer

Privacy Officer

Compliance Manager

Healthcare Administrator

Rehabilitation Director

Clinical Director

Front Desk Coordinator

Insurance Coordinator

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