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OT Intake Form 2:
Client Health Information

First name*

Last name*

Date of Birth*

Día

Mes

Año

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:*

Check all current health services: *

Home Health Aid

Nursing

Occupational Therapy

Physical Therapy

Physician (Doctor)

Psychology or Psychiatry

Social Services

Speech Therapy (SLP)

None of the Above

Other

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

Medication List

Independently keeping track of my medications is:*

Easy

Slightly challenging

Very challenging

Someone else does that for me

I don't take medications

I frequently feel:

Pain

Numbness, tingling, or “pins and needles”

Weakness

Fatigue, tired, out of energy

Unsteady, loss of balance

Dizzy or lightheaded

Worried about falling and/or getting hurt

Shortness of breath

Sad, down, blue, or hopeless

Tense or anxious

Alone or isolated

Uninterested in doing fun things

Lack of control over my life

Difficulty concentrating

Difficulty remembering things

Other

Most people fall from time to time. 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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