PRE-VISIT INTAKE QUESTIONNAIRE
DEMOGRAPHIC INFORMATION
REFERRAL INFORMATION
Who referred you?
If referred by a specific physician, mental health care provider, or other specialist, please provide
his/her name, specialty and contact information below:
PRESENTING PROBLEM
Have you noticed any of these additional symptoms? Please check those that apply to you.
Please indicate if you are independent or need help with any of the following.
Task
Do not need help
Need help
Who helps?
Feeding yourself
Getting from bed to chair
Getting to the toilet
Getting dressed
Bathing
Using the telephone
Taking your medicines
Preparing meals
Managing money / financial
Doing laundry
Doing housework
Grocery shopping
Driving
Doing “handyman” tasks
Climbing stairs
Getting to places beyond walking
MEDICAL HISTORY
Eye and Ear Problems
Heart Problems
Cataracts
Heart attack
Glaucoma
High Blood Pressure
Macular Degeneration
Heart Failure
Hearing Loss
Irregular Heartbeats (arrhythmia)
Do you use hearing aids?
Atrial Fibrillation
Do you utilize corrective lenses?
Aortic Stenosis
Lung/Pulmonary Problems
Bone and Joint Problems
Asthma
Gout
Emphysema
Osteoporosis
COPD
Fracture
Bronchitis
Metabolic/Endocrine Problems
Urinary and Kidney Tract Problems
Diabetes
Kidney Disease
Hyperthyroid/High Thyroid
Prostate Disease
Hypothyroid/Low Thyroid
Frequent Bladder Infections/UTI
Pituitary Gland Tumor
Hashimoto’s Disease
Neurological Conditions
Dementia
Huntington’s Disease
Stroke
Toxin Exposure
Epilepsy/ Instances of Seizures
Head Injury
Parkinson’s Disease
Gastrointestinal Problems
Other Health Conditions
Ulcers
Allergies
Diverticulitis
High Cholesterol
Heartburn
Sleep Apnea
Irritable Bowel Syndrome
Blood Disorders
Crohn’s Disease
Thrombosis
Celiac Disease
Cancer
Ulcerative Colitis
Sexual Dysfunction
Gallbladder Disease
Other:
Other:
Other:
Recent Physical Symptoms
Other Health Conditions
Loss of Consciousness/Fainting
Tremors
Dizziness
Shuffling/Slow Gait
Loss of Balance
Low Energy
Headaches
Shortness of Breath
Change in smell
Change in taste
Incontinence
Bowel Issues
Blurred Vision
Mis-reaching for items (e.g. door handles)
Neuropathy/ Loss of Sensation/Tingling
Sleep Difficulties
Slurred Speech
Difficulties Swallowing:
Other:
Other:
SURGERY
Date
1.
2.
3.
Please indicate if you are independent or need help with any of the following.
