Patient History Form

Your Full Name*

First

Last

Date of Birth*

Age*

Gender Identity and/or Preferred Pronoun*

Cell Phone:*

Home Phone

Work Phone

Mailing Address (Street, City, State, Zip)*

Email*

Preferred Method of Contact:*

Cell

Work

Home

Legal Guardian through DHS? Please include case worker name, contact, and Medicaid ID.

Emergency Contact Name*

Emergency Contact Phone Number*

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Insurance Information >

Primary Insurance Provider*

Policy Holder Name and DOB*

Primary Member ID*

Group ID or Group Name*

SSN

Insurance Provider Phone

Send Claims To:

Street Address City State / Province / Region Postal / Zip Code Country

Secondary Insurance Provider

Secondary Policy Holder Name and DOB

Secondary Member ID

Secondary Group ID or Group Name

Secondary Insurance Provider Phone

Send Secondary Claims To:

Street Address City State / Province / Region Postal / Zip Code Country

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Medical History

What is the reason for seeking occupational therapy evaluation or services? *

What are your strengths? What leisure activities do you enjoy? *

What is your primary concern at this time? What tasks are difficult for you to perform?*

Are you employed? If so, briefly describe your job.*

What would you like to learn from our evaluation?*

What specific tasks or functional activities would you like to address?*

What is your preferred learning style/How do you learn best? (i.e. visual learner, auditory learner, etc.)*

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Attachments

Do you have any concerns regarding work? Please specify.*

Do you have any concerns regarding your ability to participate in leisure activities? Please specify.*

Describe your self-care routines (how do you relax, calm yourself down, maintain overall wellness?).*

Do you enjoy socializing or do you prefer spending time alone?*

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Patient History Form – Adult

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