Name:

Birthdate:

Today’s date:

Financial #:

Outpatient Physical/ Occupational Therapy Intake

PLEASE COMPLETE ALL OF THE FOLLOWING. THANK YOU.

History of the Present Illness
What is the reason for your visit today?
Provider Hx. Comments:

Pain Assessment

Do you have pain now? / Yes / No / If yes, when did it start?______
If patient answered yes above, continue with questions below.
If patient does not have pain, he/she can skip the section below
Pain intensity: On a 0-10 scale (0 = no pain, 5 = moderate pain, 10 = very severe pain), how would you rate your pain:
Average Pain Currently: _____ / At it’s worst: _____ / At it’s best: ____
On a 0-10 scale, at what level of pain are you able to function as you want? ______
Is your current pain: / Constant / Intermittent / If intermittent, what percentage of the day do you have pain? ______%
Location of pain:______
Describe your pain (aching, burning, stabbing, etc.):______
______
Do you have any of the following symptoms: / Numbness / Tingling / Pins / Needles / Limb falling asleep
If so, in what locations of your body? ______
What causes your pain to increase? ______
______
What relieves your pain? ______
______
What time of day is your pain worse: / Morning / Mid-day / Evening / Night
If morning, do you feel: / Stiff / Sore
What “everyday” activities are limited by your current pain (work, driving, laundry)? ______
______
Which of the following are associated with your pain?
Altered sleep / Nausea / Change in appetite / Impaired concentration
Impaired mobility / Depression / Irritable / Other
Since your pain began, are you: / Getting Better / Getting Worse / Staying the same
Have you had the same or similar pain before? / Yes / No / If yes, when? ______
Have you previously received treatment for this condition from: / Physical Therapist / Occupational Therapist / Doctor / Chiropractor / Other: ______
Briefly describe the treatment you received: ______
What is your main goal in coming to Physical/ Occupational Therapy? ______
For Provider Use Only (other subjective complaints/comments):
For Provider Use Only: Premorbid Status

Rev.9/06/06 Therapist’s Initials: ______Date: ______


Name:

Birthdate:

Financial #:

General Personal Information / Social History

Hand dominance: / Right / Left
Marital Status: / Single / Married / Widowed / Divorced / Do you have young children to take care of? ______
Are you the sole person at home responsible for: cooking? laundry? cleaning? shopping?
Occupation: ______/ Are you currently employed?: / Yes / No
Work Status: / N/A / Full Duty / Retired / Off because of current injury: How long?
Work with restrictions / If yes, what are current restrictions:______
Positions/ Physical Demands at work: ______
______
Recreational Activities/ Sports include:______
Do you exercise regularly? / Yes / No / If yes, how many times per week?______
What exercise equipment do you have at home? ______
Do you currently smoke? / Yes / No / If so, how many packs a day?______; For how many years? ______
If not, were you a former smoker? / Yes / No / When did you quit? ______
Do you drink alcohol? / Yes / No / Amount per week: ______drinks per (check one) day; week; month
Overall, would you describe your sleep as: / Good / Fair / Poor
In what position do you prefer to sleep? / Back / Stomach / Right side / Left side / Other:______
How many times per night do you wake?_____ / Is the reason you wake up related to your current problem: / Yes / No
Do you currently take medication to sleep? / Yes / No
If yes, what kind? / Pain / Muscle relaxant / Other:______
I currently use a: Walker Rolling Walker Cane Crutches Brace Splint Other: ______

How do you best learn? pictures reading listening demonstration other:______

Home Environment

I live in a(n): / 1-story house / 2-story house / Apartment / Other: ______
I live: / Alone / With my spouse / With my children / With a roommate/ friend / With my significant other
With my parents / With a caregiver / Other: ______
Do you take care of anyone else (elderly parent, spouse, disabled child)? / Yes / No / Full time Part time
If yes, what duties do you perform? ______
My bedroom is located: / On first floor / On second floor / In the basement / I must sleep elsewhere: ______
Shower/ Bathing is located: / On first floor / On second floor / In the basement
A toilet is accessible to me / On first floor / On second floor / In the basement
Laundry is located: / On first floor / On second floor / In the basement / No in-home laundry
Number of steps to enter house? / _____ / Going up, railing is on: / Right / Left / Both sides / No Railings
Do you feel your home is designed to prevent injuries? / Yes / No

Diagnostic Testing

Please list any tests you have had for any condition in the last 3 months (X-ray, MRI, EMG, CT scan, etc.)
Name of Test / Date of Test / Result

Nutritional History

My eating habits are: Good Fair Poor
Has there been any change in your appetite in the past 6 months? Yes No
Have you gained or lost weight (more than 10 pounds) in 1 month without wanting to? Yes No
If yes, how much gain or loss? ______
Are you happy with your weight? Yes No
If no, are you on a diet and exercise program? Yes No
For women: Are you taking any extra calcium? Yes No

Therapist’s Initials: ______Date: ______

Name:

Birthdate:

Financial #:

Current Medications

Please list all medications you are now taking, including those you buy without a doctor’s prescription (such as aspirin, cold tablets, nutritional supplements, and/or herbal medicines). If you have a current list of medications, you may give it to us and omit this section.

Prescriptions

/

Prescriptions

/

Over-the-counter

/

Herbals/ vitamins

Past Medical History

Please check or list current and past medical problems that you have been treated for:
Cancer
Diabetes
Heart Disease
High Blood Pressure
CVA - Stroke
Gout / Osteoarthritis
Rheumatoid Arthritis
Headaches
Osteoporosis
Metal Implants
Pacemaker / Loss of Bowel Control Loss Bladder Control
Epilepsy
Asthma
Breathing Difficulties / Bleeding Problems
Emphysema
Chronic Bronchitis
Sinusitis
Infections
Intestinal Disorders / Circulatory Problems
Liver Problems
Gallbladder Problems
Thyroid Problems
Currently Pregnant
Do you have a history of falls or loss of balance? Yes No If yes, loss of balance is: frequent rare
If yes for falls, how many falls in the last: Week? ______Month? ______
Other Illnesses, Medical Problems or Injuries / Year / Physician who Treated you
For Provider Use Only (additional information gained during evaluation):

Past Surgical History

Please list your previous surgeries, and the year that you had the surgery done.

Surgery

/ Hospital / Year
Allergies and Sensitivities
List any allergies to medications or any thing else and how it affects you

Allergic to

/ Reaction / Allergic to / Reaction
Do you have an allergy to LATEX? No Yes

Patient- Do not fill in the section below

For Provider - Assessment of Patient Learning Needs

Current knowledge/ understanding of basic info: / None / Minimal, needs reinforcement / Understands info/ skills for self-care
Education needs identified on evaluation: / disease information / equipment use / safety / ADLs / exercise
Barriers to learning: / none / vision / cannot read / hearing / cannot comprehend / language/needs interpreter / other:
Readiness for learning: / accepting / denying / no interest / refuses
Signature of Patient - I verify the above information is accurate to the best of my knowledge / Date
Provider Signature – I certify that I have reviewed the contents of this intake form with the patient / Date

Rev.9/06/06