Order Number Adult Intake Packet Date of evaluation: * Patient Information First Name: * HIPPA Required Field. Last Name: * HIPPA Required Field. Email: * HIPPA Required Field. Date of Birth: * Social Security #: * Marital Status: * Married Single Divorced Widowed Address: * City: * State: * Zipcode: * Specialty Doctor/Phone: Fax #: Primary/Family Physician: Primary/Family Physician Phone: Fax #: Employer: Employer Address: Employer City: Employer State: Employer Zipcode: Work Status: * FT PT Retired Student Unemployed Disabled Gender * Body Part RX Date: Date of Injury/Onset: The onset date is date the first injury occurred. Diagnosis: Emergency Contact Name: * Emergency Contact Phone: * Past Medical History Questionnaire Reason for Therapy: * Date of Injury/Onset: The onset date is date the first injury occurred. Have you ever received therapy for the condition mentioned above? * Yes No Treatment received: Previous Treatment: Successful Unsuccessful Can you be/are you pregnant?: * Yes No Do you now or have you ever had any of the following conditions? Conditions: Arthritis Hearing Loss Osteoporosis Depression High Blood Pressure Anxiety Heart Disease Substance Abuse Heart Attack Diabetes Pace Maker Anemia Vascular Disease Hypersensitivity to Hot/Cold Stroke Swelling in Ankles Asthma Deep Vein Thrombosis (DVT) Conditions (continued): Shortness of Breath Seizures/Epilepsy Chronic Cough Metal in Body/Surgical Implants Fainting Spells Cancer/Tumor Thyroid Problems Recent Weight Loss/Gain Headaches Current Infection(s) Head Injury/Concussion Tuberculosis Hernia Hepatitis Kidney/Previous Fractures Previous Surgeries Other If you answered “yes” on any of the above, please explain and give approximate date(s): Do you have any allergies: Yes No Are you presently taking any medications?: * Yes No Communication & Language Use Uses Words: * Yes No Uses Sentences: * Yes No Omits small words (of, the, and, etc.): * Yes No Words that seem to be difficult: Easier words: Most difficult communication activities: Understands TV or radio: Yes No Reads/Understands newspaper: * Yes No Follows simple requests or instructions: * Yes No Relies on Gestures: * Yes No Relies on other means of communication: * Yes No Do family members try to fill in words or talk for client? * Yes No Do family members anticipate or guess client’s needs by communicating? * Yes No Makes change or handles money: * Yes No Gets lost in conversations or complicated instructions: * Yes No Yes, The information is correct to the best of my knowledge. Privacy Policy * Signature of Patient/Legal Guardian *
