Occupational Therapy Intake Form

Occupational Therapy Patient Intake Form
First Time Visit?

YesNo
If No, when was the last visit?

MonthDayYear
Date
What is your reason for the visit?
Personal Information
Name

First NameLast Name
Age
Sex

MaleFemale
Date of Birth

MonthDayYear
Date
SS#
Marital Status

SingleMarriedDivorcedWidowedRather not say
Occupation
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Name
Phone Number

Area CodePhone Number
E-mail
Emergency Contact
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relation
Referring Physician

First NameLast Name
Physician's Phone Number

Area CodePhone Number
Primary Care Physician Name

First NameLast Name
Insurance Information
Name of Insurance Company
Policy #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insured's Name

First NameLast Name
Insured's SS#
Date of Birth

MonthDayYear
Date
Insured’s Employer Name:
Insured's relationship to patient
Current Symptoms
Reason for your visit
Rate your chief complaint in order of severity from worst (5) to least (1)
Indicate the nature of your pain and symptoms

SharpDullPiercingShootingAchingTinglingNumbnessStabbing
What makes your condition worse?
What makes your condition better?
How often do you experience the pain/symptoms?
Are your symptoms related to a work injury?

YesNo
Or a motor vehicle accident?

YesNo
List past surgeries or major medical problems/illness*
List of Medication*
Since your symptoms began, have you noticed any of the following

FatiguePain at nightLeg swellingWeight loss/gainNumbness or tinglingAbdominal painFaintingSkin changesHeart palpitations
History

	Yes	No
Tobacco Use
Alcohol Use
High Blood Pressure
Neck or Back Problems
Are you pregnant
Do you have osteoporosis
Allergies

Are you currently under a care of any healthcare provider other than who prescribed your Physical Therapist

YesNo
If yes, what is the reason?
Schedule

Desired time and day of the meeting.
Day
Time
Comments
Authorization/Consent
- I hereby authorize the specific personnel/healthcare facility to gather all the necessary details needed for my appointment to ensure the safety of both the patient and the therapist.
- I understand that my personal health information is subject to disclosure by the facility receiving it for legal purposes.
- I understand that I have the right to restrict how my personal health information is used and disclosed for treatment, payment and administrative operations if I notify the practice.
- I authorize my insurance benefits to be charged directly the facility and that I am responsible for any cost in any case my insurance claim be denied.
Name & signature of patient/legally responsible person

Clear
Reason why patient is unable to sign
Date Signed

MonthDayYear
Date
Drivers License

Browse Files

Cancelof
Social Security Card

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Medicare Card

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Cancelof
Prescription Upload

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Should be Empty:

Occupational Therapy Patient Intake Form

Personal Information

Emergency Contact

Insurance Information

Current Symptoms

History

Schedule

Authorization/Consent