The Physical Therapy Patient Intake Form Template by WPForms is designed for physical therapy clinics and practitioners who want to streamline the patient intake process and manage patient information effectively.
How Does the Physical Therapy Patient Intake Form Template Work?
The Physical Therapy Patient Intake Form Template requires the WPForms Pro License and the Signature Addon to ensure a seamless and user-friendly experience for both therapists and patients. Fields include:
- Patient Information
- Name: Captures the full name of the patient.
- Date of Birth: Essential for patient records and age verification.
- Age: Automatically calculated from the date of birth for convenience.
- Gender: Important for personalizing care and understanding demographics.
- Email: For communication and sending important information.
- Phone: A direct contact number for scheduling or urgent communication.
- Medical History:
- Current Health Conditions: Information about any existing health issues.
- Past Medical Conditions: Details of previous medical history that is relevant.
- Allergies: Critical for ensuring patient safety during treatment.
- Current Medication: Helps in understanding ongoing treatments.
- Previous Medications: Provides a background on the patient’s medication history.
- Family Medical History: Offers insights into genetic or familial health issues.
- Current Condition:
- Reason for Visit: The primary condition for which the patient seeks therapy.
- Date of Onset: When the patient first noticed the symptoms or issue.
- Aggravating Factors: Conditions or activities that worsen the symptoms.
- Alleviating Factors: Things that provide relief or improve symptoms.
- Description of Symptoms: A detailed account of the patient’s experience.
- Pain Scale: A number slider field to gauge the intensity of pain.
- Emergency Contact:
- Name: Contact for emergencies during therapy sessions.
- Relationship: The relationship of the emergency contact to the patient.
- Phone Number: Direct line to the emergency contact.
- Email: Additional contact method for the emergency contact.
- Consent and Authorization:
- Receive physical therapy services: Patient’s agreement to undergo therapy.
- Perform diagnostic procedures: Approval for necessary diagnostic methods.
- Charges not covered by insurance: Acknowledgment of financial responsibility.
- Signature and Date: Formal consent and verification of the information provided.
Sign up with WPForms today and access the Physical Therapy Patient Intake Form Template. It is perfect for streamlining the intake process, allowing therapists to focus more on patient care and less on paperwork.
