Get in TouchClient Intake Form "*" indicates required fields CompanyThis field is for validation purposes and should be left unchanged.PRE-VISIT INTAKE QUESTIONNAIREDate of Evaluation:* MM slash DD slash YYYY DEMOGRAPHIC INFORMATIONFull Name* First Name: Middle Name: Last Name: Your Address* Street Address: Apartment/Unit (if applicable): City: State: AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code: Phone Number:*Date of Birth:* MM slash DD slash YYYY Age:Email:* Gender:* Male Female Who is your primary care provider?*Email: Address:*Phone Number:*Fax Number:May we contact your physician?* Yes No PRESENTING PROBLEMPlease briefly describe what problem(s) with thinking you are experiencing:Please indicate if you are independent or need help with any of the following.TaskNeed HelpFeeding yourselfFeeding yourself Yes/No Yes No DrivingDriving Yes/No Yes No IncontinenceIncontinence Yes/No Yes No BathingBathing Yes/No Yes No DressingDressing Yes/No Yes No TransferringTransferring Yes/No Yes No Homemaking Homemaking Yes/No Yes No AmbulationAmbulation Yes/No Yes No Meal PrepMeal Prep Yes/No Yes No Med RemindersMed Reminders Yes/No Yes No Do you receive help in your home (e.g. family member, paid home health worker)? Yes No How many days per week?How many hours per day?Who Helps?MEDICAL HISTORY Eye and Ear ProblemsHeart ProblemsCataracts Yes No Heart attack Yes No Glaucoma Yes No High Blood Pressure Yes No Macular Degeneration Yes No Heart Failure Yes No Hearing Loss Yes No Irregular Heartbeats (arrhythmia) Yes No Do you use hearing aids? Yes No Atrial Fibrillation Yes No Do you utilize corrective lenses? Yes No Aortic Stenosis Yes No Other:Other:Lung/Pulmonary ProblemsBone and Joint ProblemsAsthma Yes No Gout Yes No Emphysema Yes No Osteoporosis Yes No COPD Yes No Fracture Yes No Bronchitis Yes No Other:Other:Metabolic/Endocrine ProblemsUrinary and Kidney Tract ProblemsDiabetes Yes No Kidney Disease Yes No Hyperthyroid/High Thyroid Yes No Prostate Disease Yes No Hypothyroid/Low Thyroid Yes No Frequent Bladder Infections/UTI Yes No Pituitary Gland Tumor Yes No Other:Hashimoto’s Disease Yes No Other:Neurological ConditionsDementia Yes No Huntington’s Disease Yes No Type Identified:Stroke Yes No Toxin Exposure Yes No Date MM slash DD slash YYYY Type:Date: MM slash DD slash YYYY Epilepsy/ Instances of Seizures Yes No Head Injury Yes No Number of Injuries:Date of Injury: MM slash DD slash YYYY Parkinson’s Disease Yes No Other:Gastrointestinal ProblemsOther Health ConditionsUlcers Yes No Allergies Yes No Diverticulitis Yes No High Cholesterol Yes No Heartburn Yes No Sleep Apnea Yes No Irritable Bowel Syndrome Yes No Blood Disorders Yes No Crohn’s Disease Yes No Thrombosis Yes No Celiac Disease Yes No Cancer Yes No Ulcerative Colitis Yes No Sexual Dysfunction Yes No Gallbladder Disease Yes No Recent Physical SymptomsOther Health ConditionsLoss of Consciousness/Fainting Yes No Tremors Yes No Dizziness Yes No Shuffling/Slow Gait Yes No Loss of Balance Yes No Low Energy Yes No Headaches Yes No Shortness of Breath Yes No Change in smell Yes No Change in taste Yes No Incontinence Yes No Bowel Issues Yes No Blurred Vision Yes No Mis-reaching for items (e.g. door handles) Yes No Neuropathy/ Loss of Sensation/Tingling Yes No Sleep Difficulties Yes No Slurred Speech Yes No Difficulties Swallowing: Yes No SURGERYDate1.Date MM slash DD slash YYYY 2.Date MM slash DD slash YYYY 3.Date MM slash DD slash YYYY HOSPITALIZATION REASONDate1.Date MM slash DD slash YYYY 2.Date MM slash DD slash YYYY 3.Date MM slash DD slash YYYY SignatureCAPTCHA
