Patient Information
- Full Name: _________________ Date of Birth: _________________
- Address: _________________ City/State/ZIP: _________________
- Phone: (Home) _________ (Cell) _________ (Work) _________
- Email: _________________ Preferred Contact Method: □ Phone □ Email
- Emergency Contact: _________________ Phone: _________________
- Primary Care Physician: _________________ Phone: _________________
Insurance Information
- Primary Insurance: _________________ ID#: _________________
- Secondary Insurance: _________________ ID#: _________________
- Policy Holder Name: _________________ Relationship: _________________
Medical History
Current Symptoms/Concerns
- Primary Reason for Visit: _________________
- Date of Onset: _________________
- Current Pain Level (0-10): _________________
- Previous OT/PT Treatment? □ Yes □ No
Medical Conditions (Check all that apply)
□ Arthritis
□ Heart Condition
□ Diabetes
□ High Blood Pressure
□ Neurological Condition
□ Other: _________________
Current Medications
- List all medications: _________________
- Allergies: _________________
Functional Status
Activities of Daily Living (Rate difficulty 1-5)
- Dressing: ___
- Bathing: ___
- Meal Preparation: ___
- Writing: ___
- Work Tasks: ___
Authorization
- I authorize the release of any medical information necessary to process insurance claims
- I authorize payment of medical benefits to the occupational therapy provider
Signature: _________________ Date: _________________