OT Intake Client Health Information

First name

Last name

Date of Birth

Month

Day

Year

Would you say that your health is currently excellent, very good, fair, or poor?

Excellent

Very Good

Fair

Poor

Please list all current health conditions, date(s) of onset, and how the health condition(s) currently impact(s) your life:

List all current medications (prescription and over the counter):

Medication List

What do you feel is your current risk of falling or getting injured in your home?

How many times have you fallen in the last three months?

How many times have you fallen in the last year?

If you remember details about the fall(s), please share them. Knowing where the fall happened, what happened right before, and whether or not you were injured will help the occupational therapist get a better understanding.

What are your goals for the upcoming appointment(s)? What do you want to gain or achieve?

Is there anything else that you would like the occupational therapist to know?

All of the information here provided is complete and correct to the best of my knowledge.

Signature of Client or Legally Responsible Person

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Date

Month

Day

Year

Name of Signer and Relationship to Client

OT Intake Form 2: Client Health Information

OT Intake Form 2:
Client Health Information