Adult Intake Packet

Patient Information

The onset date is date the first injury occurred.

Past Medical History Questionnaire

The onset date is date the first injury occurred.

Have you ever received therapy for the condition mentioned above? *

Previous Treatment

Can you be/are you pregnant? *

Do you now or have you ever had any of the following conditions?

Conditions

Do you have any allergies?

Are you presently taking any medications? *

Communication & Language Use

Uses Words *

Follows simple requests or instructions *

Uses Sentences *

Relies on Gestures *

Omits small words (of, the, and, etc.) *

Relies on other means of communication *

Do family members try to fill in words or talk for client? *

Do family members anticipate or guess client’s needs by communicating? *

Understands TV or radio

Makes change or handles money *

Reads/Understands newspaper *

Gets lost in conversations or complicated instructions *