Physical Therapy Intake Form Template - England and Wales

Physical Therapy Intake Form for the United Kingdom

Physical Therapy Intake Form Template for England and Wales

A comprehensive intake form used in England and Wales for collecting essential patient information before commencing physical therapy treatment. The document ensures compliance with UK healthcare regulations, data protection laws, and professional standards while gathering medical history, consent for treatment, and relevant personal information. It serves as both a legal record and a clinical tool for assessment and treatment planning.

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What is a Physical Therapy Intake Form?

The Physical Therapy Intake Form Template is a fundamental document used across healthcare settings in England and Wales to initiate the therapeutic relationship between practitioners and patients. This form captures crucial patient information, including medical history, current symptoms, and consent for treatment, while ensuring compliance with UK GDPR, healthcare regulations, and professional standards. It serves as the primary documentation tool for new patient consultations and helps establish the basis for treatment planning and progress monitoring.

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

1. Patient Information: Basic personal details including name, date of birth, address, contact information, NHS number, and emergency contacts

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

3. Consent and Authorization: Treatment consent, data processing authorization under UK GDPR, and privacy notice acknowledgment

4. Current Symptoms: Detailed assessment of present condition, pain levels, functional limitations, and onset of symptoms

5. Privacy Notice: GDPR-compliant information about how personal data is collected, processed, stored, and patient rights regarding their data

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

1. Insurance Information: Details of private medical insurance including policy number, insurer details, and coverage information

2. Workplace Injury Details: Specific information related to work-related injuries, including employer details and accident circumstances

3. Sports Activity History: Detailed information about sports participation, training regimens, and related injuries

4. Lifestyle Assessment: Information about daily activities, occupation, and lifestyle factors affecting physical health

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

1. Pain Diagram: Anatomical body diagram for patients to mark pain locations and types

2. Functional Assessment Scale: Standardized assessment form for evaluating patient's functional capabilities and limitations

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

4. Patient Rights Information: Detailed information about patient rights under NHS guidelines and relevant legislation

Authors

Alex Denne

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

Cost

Free to use

Relevant legal definitions

Clauses

Relevant Industries

Healthcare
Sports Medicine
Rehabilitation
Occupational Health

Relevant Teams

Physical Therapy
Medical Records
Compliance
Reception

Relevant Roles

Physical Therapist
Physiotherapy Practice Manager
Clinical Director
Healthcare Administrator

Industries

UK GDPR and Data Protection Act 2018: Core data protection legislation governing how personal and medical data must be collected, processed, stored and protected. Requires explicit consent for data processing and specific privacy notices.

Privacy and Electronic Communications Regulations (PECR): Regulations governing electronic communications and the protection of privacy in digital communications, relevant for any electronic record keeping or communication systems.

Health and Social Care Act 2012: Primary legislation governing healthcare provision in England, setting standards for healthcare services and patient care requirements.

HCPC Standards: Health and Care Professions Council standards that regulate physiotherapy practice and set requirements for professional conduct, competence, and ethics.

CSP Guidelines: Chartered Society of Physiotherapy guidelines providing specific standards and best practices for physiotherapy treatment and documentation.

Mental Capacity Act 2005: Legislation protecting people who may lack capacity to make certain decisions, requiring assessment and documentation of capacity for consent.

Health and Social Care (Quality and Safety) Act 2015: Legislation establishing requirements for quality and safety in healthcare services, including documentation and reporting standards.

NHS Constitution: Establishes the principles and values of the NHS in England, including patient rights and responsibilities that must be reflected in healthcare documentation.

Access to Health Records Act 1990: Legislation governing patients' rights to access their health records and requirements for medical record maintenance.

Medical Act 1983: Fundamental legislation governing medical practice and record-keeping requirements in the UK healthcare system.

Equality Act 2010: Legislation requiring equal treatment and accessibility in healthcare services, including consideration for form design and service provision.

Consumer Rights Act 2015: Legislation protecting consumers' rights in service provision, including healthcare services, requiring clear terms and conditions.

Consumer Protection Act 1987: Legislation providing protection for consumers regarding services and products, including healthcare services and documentation requirements.

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Medical Intake Form

A standardized template for collecting patient information in England and Wales, compliant with UK healthcare and data protection regulations.

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What is a Physical Therapy Intake Form?

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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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