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The Physical Therapy Intake Form is a crucial document used at the initiation of physical therapy services in Indonesia. It must comply with Indonesian healthcare regulations, particularly Law No. 36 of 2009 on Health and specific physical therapy practice requirements under Minister of Health Regulation No. 80 of 2013. This form should be completed prior to the first physical therapy session, collecting comprehensive patient information including medical history, current symptoms, insurance details, and required legal consents. It serves multiple purposes: establishing the therapeutic relationship, documenting patient condition, ensuring informed consent, and creating a legal record of the treatment agreement. The form is designed to protect both the healthcare provider and patient while facilitating effective treatment planning and regulatory compliance.

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

2. Insurance Information: Details of health insurance coverage, policy numbers, and primary insurance holder information

3. Current Condition: Description of the present injury or condition, including onset date, symptoms, and pain levels

4. Medical History: Past medical conditions, surgeries, medications, and allergies

5. Pain Assessment: Detailed pain evaluation including location, intensity, and pain diagram

6. Lifestyle & Occupational Information: Daily activities, work requirements, and lifestyle factors affecting condition

7. Consent for Treatment: Legal authorization for physical therapy treatment and acknowledgment of risks

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

9. Payment Policy: Financial responsibility acknowledgment and payment terms

10. Signature Section: Patient (or guardian) signature and date, witnessing signatures if required