Consumer Interview And Consent Form printable pdf download

Consumer Interview and Consent Form

SW Therapy & Rehab, LLC

EIN: 27-3506899, NPI 1134299555

Name: ______________________________________________________________ Date: _______________

Address: ____________________________________________

Home Phone: ___________________

______________________________________

Office/ Cell Phone: _______________

____________________________________________

Fax: ___________________________

E-mail Address: _______________________________________

PERSONAL HISTORY

Date of Birth: ________________Current age: _____

Height: ______Weight:_______

Marital Status: Single _____

Married _____

Divorced _____

Widowed _____

Occupation: __________________________________________FT: _____ PT: _____ Hrs. per Wk: ________

Spouse’s Name: __________________________________________ Occupation: ______________________

Number and Ages of: Siblings:________________________________________________________________

Children: _______________________________________________________________

Grandchildren: ____________________________________________________________

Family members now deceased and cause of death:_________________________________________________

__________________________________________________________________________________________

Parent’s marital status during childhood: _________________________________________________________

Where did you grow up? ______________________________________________________________________

List any significant events, accidents, traumas and the date they occurred:

___________________________________________________________________________________________

List any medications you are currently taking: _____________________________________________________

___________________________________________________________________________________________

Do you Smoke? Yes ____ No ____ If yes, how often/ for how long: __________________________________

Do you drink alcohol? Yes ____ No ____

If yes, what types and how often: _____________________________________________________

Do you use stimulants (Coffee, tea drugs, etc.)? Yes ____ No ____

If yes, what types and how much: _____________________________________________________

Physician’s Name: ___________________________________(MD, DO, DC, OMD) Phone: _______________

Who referred you to SW Therapy & Rehab, LLC? ______________________________________

Relationship: _______________________________

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Consumer Interview And Consent Form