Pt Intake Form Template for Philippines

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Key Requirements PROMPT example:

Pt Intake Form

"I need a PT Intake Form for my new physical therapy clinic opening in Manila in January 2025, compliant with Philippine regulations and suitable for both sports injury and elderly patients, with additional sections for insurance processing."

Document background

The PT Intake Form is a crucial document used in physical therapy practices throughout the Philippines to initiate the provider-patient relationship and ensure compliance with local healthcare regulations. This form must be completed before commencing physical therapy services and serves multiple purposes: documenting patient medical history, current conditions, and symptoms; obtaining informed consent for treatment; ensuring compliance with the Physical Therapy Law (RA 5680) and Data Privacy Act; and establishing the basis for treatment planning. The form includes necessary provisions for insurance processing and emergency contacts, while incorporating required health screening elements and privacy protection measures as mandated by Philippine healthcare authorities.

Suggested Sections

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

2. Medical History: Current medical conditions, past surgeries, medications, and allergies

3. Current Condition: Details about the presenting condition, symptoms, pain assessment, and onset of problems

4. Lifestyle and Occupational Information: Daily activities, work requirements, and lifestyle factors affecting physical condition

5. Previous Treatment History: Past physical therapy, other medical treatments, and their outcomes

6. Pain Assessment: Detailed pain scale, location mapping, and pain characteristics

7. Consent for Treatment: Informed consent for physical therapy treatment and acknowledgment of risks

8. Privacy Policy Acknowledgment: Patient acknowledgment of privacy practices and data handling policies

9. Payment and Insurance Information: Insurance details, payment preferences, and billing information

Optional Sections

1. Sports/Athletic History: For patients involved in sports or athletic activities, including training routines and injury history

2. Post-Surgery Protocol: For post-operative patients, including surgeon's protocol and restrictions

3. Work-Related Injury Information: For workplace injuries, including incident details and worker's compensation information

4. Pregnancy Considerations: For pregnant patients, including gestational age and pregnancy-related symptoms

5. Balance Assessment Authorization: For elderly patients or those with balance concerns

6. Pediatric Development History: For patients under 18, including developmental milestones and growth history

Suggested Schedules

1. Body Diagram: Anatomical diagram for marking areas of pain, discomfort, or injury

2. Pain Scale Reference: Standard pain scale with descriptions for patient reference

3. Physical Activity Readiness Questionnaire (PAR-Q): Standard health screening questionnaire

4. Functional Assessment Scale: Detailed assessment of patient's current functional capabilities

5. Treatment Consent Forms: Detailed consent forms for specific treatment modalities

6. Insurance Information Forms: Detailed insurance and billing authorization forms

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

alex.den.21@genieai.co

Relevant legal definitions

Clauses

Relevant Industries

Healthcare

Medical Services

Rehabilitation Services

Physical Therapy

Sports Medicine

Occupational Health

Insurance

Relevant Teams

Physical Therapy

Rehabilitation

Patient Administration

Medical Records

Compliance

Quality Assurance

Front Office

Insurance Processing

Clinical Operations

Legal

Relevant Roles

Physical Therapist

Rehabilitation Specialist

Clinical Director

Healthcare Administrator

Medical Records Officer

Insurance Coordinator

Compliance Officer

Front Desk Coordinator

Patient Care Coordinator

Quality Assurance Manager

Find the exact document you need

Pt Intake Form

A Philippine-compliant physical therapy intake form for collecting patient information, medical history, and treatment consent under local healthcare regulations.

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Authors

Alex Denne

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