Patient Information Form

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Patient Information Form
Date _______________
Patient # ____________
Name _________________________________ Date of Birth____________ Age_____ SS#________________
Address______________________________________City________________State______ Zip Code________
Home Phone________________________________ Cell Phone___________ Sex____ Marital Status_________
E-mail Address_____________________________________________________________________________
Occupation____________________________ Business Name_________________________________________
Business Address____________________________________________ Business Phone___________________
Does your work expose you to any of the following?
Stress
Heavy Lifting
Hazardous Substances
Date of Injury______________________ How did injury occur? ________________________________________
Injury Area___________________________________________________ Post-OP_______________________
Primary Insurance________________________________________ Insurance ID#_______________________
Primary Holder Name______________________________________________ D.O.B.____________________
Insurance Address______________________________________________ Insurance Phone_______________
Secondary Insurance______________________________________ Insurance ID#______________________
Insurance Address__________________________________________________________________________
Insurance Phone_______________________________ Policy/Group #________________________________
Primary Doctor_______________________________________ Primary’s phone_________________________
Emergency Contact Name____________________________________ Phone Number______________________
Race:
White
Black/African American
Asian
Other
Ethnicity:
Hispanic
Non-Hispanic
Primary Language: _______________________________________
How Did You Hear About Us? Friend
Hospital
TV Doctor
PT Center
Newspaper Other______________
Have you received any outpatient physical or speech therapy in this calendar year? _____ If yes,
when?____________________________ where?________________________________
Have you received any outpatient occupational therapy in this calendar year? _____ If yes,
when?____________________________ where?________________________________
Is there any chance that you are currently
MEDICAL/SOCIAL HISTORY
pregnant?
With whom do you live?
Alone
Spouse only
Yes
No
Spouse and children
Within the past year, have you had any of
the following symptoms?
Children only
Other relatives
Other ______________________________
Chest pain
Smoke Free?
Yes
No
Heart palpitations
Where do you live?
Shortness of Breath
Private home; CIRCLE ONE 1 level/2 level
Dizziness or blackouts
Apartment; CIRCLE ONE Lower/Upper Level
Coordination problems
Assisted living/ group home
Weakness in arms or legs
Loss of balance
Other ______________________________
Difficulty walking
Does your home have: Check all that apply
Joint pain or swelling
Stairs, no railing
Stairs, railing
NUMBER OF STEPS & LOCATION
Pain at night
_____________________________________
Difficulty sleeping
Ramps
Elevator
Loss of appetite
Assistive devices _____________________
Nausea/ vomiting
Weight loss/ gain
Obstacles ___________________________
Incontinence
Do you use:
Bladder, bowel or bathroom issues
Cane
Glasses
Walker
Hearing aids
Other _________________
Wheelchair
Incontinence Products

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