Globally, there are more than fifteen thousand hospitals and health care centers established to cater the needs of patients and provide jobs to new graduates. With this, hospitals and health care centers must assure that they have all the necessary details of their patients in order to address their patient’s concerns appropriately. This is why various documents such as patient intake forms are provided to the patient as well as the patient’s authorized representative to obtain the patient’s general information.

Patient Intake Form Sample

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What is a Patient Intake Form?

A patient intake form is a document that needs to be completed by a patient or someone who is authorized by the patient upon their arrival at the health care center or hospital. This form will help in determining what treatment is suitable for the patient’s condition and how the patient can be handled by the nurses and hospital staff. Contents of the form mainly consist of the patient’s personal information and medical information. Additionally, a consent to treat statement is often included at the bottom of the form after the sections which need to be filled out with the patient’s data. The consent will allow the health care center or hospital to provide treatment, medication, and other medical procedures to cure the patient.

Another inclusion in this type of intake form is a parental consent or minor patient agreement statement. This is necessary for hospitals who commonly deal with clients who are considered as young adults, minors, toddlers, and even babies. The parental consent statement should be signed by the parent or the legal guardian of the patient before any procedure and medication will be given to the patient. Since there are some patients who have special conditions and behaviors, the parent must disclose and inform the physician about his/her child’s illness and medical history to assure that the process of curing the patient will be smooth and safe.

An emergency contact person must also be written on the patient intake form. This person is obligated to keep his/her phone lines open and available during the patient’s medical procedures. The contact person’s phone number, residential address, email address, and the relationship he/she has with the patient should be disclosed on the form.

Insurance Patient Intake Form

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How to Create a Simple Patient Intake Form

Creating a patient intake form is easy especially with the aid of today’s technology. Below are the steps that anyone must follow to have their own patient intake forms from scratch:

  • Step 1: Prepare a Blank Sheet to Work on. Regardless of the format that the hospital prefers, whether in word or in portable document file format, the blank sheet should be prepared along with the desired layout for the form. With this, the decision for the sections and inclusions to be indicated on the form must be finalized to assure that all the necessary details will not be left aside. Most patient intake forms contain two to three sections depending on the range of the data that the hospital staff will be needing from the patients.
  • Step 2: Incorporate the Hospital or the Clinic’s Name. This should be the header of the patient intake form which will then be followed by the name of the document. The clinic’s logo can also be included as well as the logos of the clinic’s partner health care providers who are sponsors for their everyday work and routines.
  • Step 3: Add a Section for the Patient’s Details. A table can be added for this section to be well-organized and arranged which promotes an ease-of-use to the patients. This section must cater the patient’s legal name, address, social security number, insurance ID number, gender, and other important factors that will help the clinic in identifying the patient.
  • Step 4: Indicate an Area Allotted for the Patient’s History. This refers to the patient’s background, family, and medical history. With these details, the administering physician assigned to the patient will be able to know the possible beginning of the patient’s issues as well as the causes of why the patient has a specific behavior and allergies. Depending on the preferred layout of the clinic or hospital, this section can be in a form of a table or in a questionnaire type where the patient can state a yes and no answer for the questions. Checkboxes can also be considered while determining the patient’s symptoms and illnesses from the previous years.
  • Step 5: State a Patient Consent and Agreement. This should be the last part of the form wherein the intentions and the objectives of the hospital will be highlighted. The agreement must then be followed with an area where the patient can affix his/her signature to indicate his/her approval and a date area that determines when the patient has completed the document.

Once the steps have been followed, the form can be printed as well as added to the hospital or clinic’s webpage. Online forms are easier to be completed by patients who are far from the establishment of the clinic while the printed form will allow the staff to acquire the details immediately from patients who are visitors in the establishment.

Physical Therapy Patient Intake Form

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Varieties of Patient Intake Forms

The varieties of patient intake forms are only a few. The most common is a healthcare patient intake form which is used by doctors, nurses, and hospital staff. This has two sections mainly patient information and an agreement section. Another variety is an insurance patient intake form which is provided by the patient’s health insurance provider. The form must indicate the insurance identification number of the patient as well as the patient’s level of insurance coverage. Lastly, a therapy patient intake form is used by those who aim to join a therapy session in order to heal one’s well-being. This intake form caters the injury and accident information of the patient if the reason for the therapy request was due to an incident leading to the patient’s broken parts.

However, regardless of the variety that hospitals and health care providers use, it is essential that they keep the information of their patients confidential to protect and promote security in their organization. The completed patient intake form must be kept along with all other medical forms that the patient was able to submit within his/her stay in the hospital’s premises.

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