Clinical Intake Form

Clinical Intake Form Template for Philippines

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Key Requirements PROMPT example:

"I need a Clinical Intake Form for my new mental health clinic opening in Manila in January 2025, which must include detailed psychological history sections and comply with both the Mental Health Act and Data Privacy Act of the Philippines."

Document background

The Clinical Intake Form is a fundamental document used across healthcare facilities in the Philippines to standardize the collection of patient information during initial visits or admissions. This document is essential for maintaining comprehensive medical records in compliance with Philippine healthcare regulations, including the Data Privacy Act of 2012 (RA 10173), the Philippine Medical Act, and relevant Department of Health guidelines. The form typically includes sections for personal information, medical history, current medications, allergies, emergency contacts, and insurance details. It serves multiple purposes: ensuring proper patient identification, establishing medical history, facilitating appropriate care planning, and meeting legal requirements for medical documentation. Healthcare providers use this form to make informed clinical decisions while maintaining proper records for both medical and legal purposes.

Suggested Sections

1. Patient Information: Basic demographic information including full name, date of birth, gender, civil status, address, contact information, and government-issued IDs

2. Emergency Contact Information: Details of primary and secondary emergency contacts including relationship to patient

3. Insurance Information: PhilHealth number, private insurance details, and other relevant healthcare coverage information

4. Medical History: Past illnesses, surgeries, hospitalizations, and current medical conditions

5. Current Medications: List of all current medications, including dosage and frequency

6. Allergies and Reactions: Documentation of known allergies to medications, foods, or environmental factors

7. Family Medical History: Relevant family medical conditions and hereditary diseases

8. Privacy Notice and Consent: Information about data privacy rights and consent for information collection as per RA 10173

9. Authorization and Signature: Patient's (or legal guardian's) signature and date, confirming accuracy of provided information

Optional Sections

1. Lifestyle Information: Optional section for collecting information about smoking, alcohol consumption, exercise habits, and dietary preferences

2. Mental Health History: Additional section for facilities that provide mental health services, in compliance with RA 11036

3. Reproductive Health History: For obstetrics/gynecology or relevant specialty clinics

4. Occupational History: For clinics dealing with occupational health or when workplace-related health issues are relevant

5. Travel History: Important during infectious disease outbreaks or for facilities in areas with high tourist traffic

6. Traditional Medicine Use: For facilities where knowledge of traditional medicine use is relevant to treatment planning

7. Dental History: For dental clinics or facilities providing dental services

Suggested Schedules

1. Schedule A: Detailed Symptoms Checklist: Comprehensive checklist of current symptoms and their duration

2. Schedule B: Pain Assessment Form: Detailed pain evaluation form including pain scale and location diagram

3. Schedule C: Vaccination History Form: Detailed record of past vaccinations and dates

4. Appendix 1: Patient Rights and Responsibilities: Document outlining patient rights and responsibilities under Philippine healthcare laws

5. Appendix 2: Privacy Policy Details: Detailed explanation of how patient information is handled, stored, and protected

6. Appendix 3: Facility-Specific Policies: Additional forms or information specific to the healthcare facility

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

alex.den.21@genieai.co

Relevant legal definitions

Clauses

Relevant Industries

Healthcare

Medical Services

Hospital Administration

Clinical Practice

Mental Health Services

Dental Services

Primary Care

Specialty Medical Care

Healthcare Insurance

Public Health

Occupational Health

Relevant Teams

Medical Records

Front Desk Operations

Clinical Operations

Administrative Services

Compliance and Legal

Quality Assurance

Patient Services

Data Management

Healthcare Information

Risk Management

Relevant Roles

Medical Doctor

Nurse

Medical Receptionist

Healthcare Administrator

Clinical Manager

Medical Records Officer

Data Privacy Officer

Compliance Officer

Quality Assurance Manager

Patient Care Coordinator

Clinic Director

Hospital Administrator

Medical Secretary

Healthcare Facility Manager

Clinical Operations Manager

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Authors

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