Adult Intake Form – Advanced Occupational Therapy Services

Name

Date of Birth *

Sex

Age

Primary Doctor

Phone Number

Caretaker's Name

Phone Number

Preferred Email Address

Paragraph Text

Preferred Mailing Address

Allergies: Please list any medication or foods that the client is allergic to (latex, peanuts, etc)

Does the client currently have any diagnosis? Please list:

Does the client currently take any prescription medications? Please list:

Has the client had any injuries, surgeries, illnesses or hospitalizations? Please list:

Does the client wear corrective lenses? Please explain type of prescription if yes.

Has the client had his or her vision checked within the past year? If no, when was the last time, and what were the results?

Please check any of the following evaluations/assessments that the client has received:

Physical Therapy Evaluation

Speech Therapy Evaluation

Psycho Educational Evaluation

Vision Therapy Assessment

Please check any of the following services that the client currently receives:

Please describe the issue of concern at home and/or work, which has facilitated this evaluation: