Individual Intake ResourcesIndividual Information and Intake FormIndividual Information and Intake Form"*" indicates required fieldsStep 1 of 812%NameThis field is for validation purposes and should be left unchanged.Name* First Last Preferred First Name*Address* Street Address City 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 State ZIP Code Email* Phone*Social Security Number*Sex* Male FemaleEthnic Origin*Primary Language Spoken*Birth Date* Marital Status* Single Married Divorced WidowedPreferred Religion*Case ManagerEmail PhonePets Yes NoPlease list all type of pets present in the home or location of serviceConsent Status Can give own consent (emancipated) Consent from guardianGuardians Yes NoType of GuardianshipEffective Date ConditionsGuardian's Name First Last Email PhoneGuardian's Name First Last Email PhoneIndividual and/or guardian received Advance Directives and was informed of their Advanced Directives options Yes NoAre there any Advance Directives currently in place? Yes NoPlease detail Advance Directives currently in placeFamily / Guardians / FriendsName First Last Relationship to IndividualPhoneAddress Street Address City State / Province / Region ZIP / Postal Code Email Contact in Emergency? Yes NoContact When ...Name First Last Relationship to IndividualPhoneAddress Street Address City State / Province / Region ZIP / Postal Code Email Contact in Emergency? Yes NoContact When ...Medical InformationDoes the individual experience seizures? Yes NoSeizure typeAre the seizures controlled? Yes NoDate of last known seizure Does the individual have allergies? Yes NoList all allergies, including plants, medication, dietary, animals, perfume, etc.Date of latest physical Date of last TB Tine test TB Tine test resultsDate of last Hepatitis B test Hepatitis B test resultsVaccination history and datesHepatitis AHepatitis BTetanusList others and latest datesOther ConditionsCheck all conditions that apply (past and current) Allergies Anemia Anxiety Arthritis Aspiration Asthma Blood transfusion Cancer Choking Clotting disorder Congestive heart failure Constipation Depression Diabetes mellitus Dysphagia Emphysema/COPD Gastroesophageal reflux disease (GERD) Glaucoma Heart murmur Hepatitis HIV/AIDS High cholesterol Hypertension/high blood pressure Immunodeficiency Incontinence (bladder) Incontinence (bowel)Insomnia Kidney disease Myocardial infarction Nerve/muscle disease Osteoporosis Seizures Brain Shunt Sickle cell anemia Substance abuse Thyroid disease TuberculosisList and describe current medical conditions not listed aboveSurgical HistoryCheck all that apply Appendectomy Appendectomy Bladder surgery Brain surgery Breast surgery Bunionectomy C-section CABG Cardiac stent Cholecystectomy Colon surgery Eye surgery Fracture surgery Hernia repair Hysterectomy Joint surgery Lung surgery Prostate surgery Small intestine surgery Spine surgery Thyroid surgery Tonsillectomy Tubal ligation Valve replacement Varicose vein surgery Vascular surgery Vasectomy Weight reduction surgeryHabits and ActivitiesDo you use tobacco? Yes NoWhat form of tobacco?How much tobacco?For how long have you used tobacco?Do you drink alcohol? Yes No Yes, in the pastHow many drinks per week?Do you, or have you ever used recreational drugs? Yes NoPlease describe you recreational drug useDo you get regular exercise? Yes NoWhat kind of exercise?How often do you exercise? Daily More than 30 minutes, 3 times per week One or two times per weekPlease list any hobbies or leisure activitiesSexual HistoryMy sexual partners have been Male Female Both I've never been sexually activeHave you had more than one sexual partner in the past year? Yes NoHave you ever had a sexually transmitted disease? Yes NoPlease describe what and whenMedical, Mental Health, and Health PractitionersPrimary Physician Name First Last PhoneAddress Street Address City State / Province / Region Emergency NumberDate of Latest Exam Appointment ScheduleMedication(s) PrescribedTreatment(s) PrescribedOB/GYN Name First Last PhoneAddress Street Address City State / Province / Region Emergency NumberDate of Latest Exam Date of Latest Mammogram Date of Latest Pap smear Medications(s) / Treatment(s) PrescribedAppointment SchedulePsychiatrist Name First Last PhoneAddress Street Address City State / Province / Region Latest Exam Date Appointment ScheduleConditionMedications(s) / Treatment(s) PrescribedNeurologist Name First Last PhoneAddress Street Address City State / Province / Region Latest Exam Date Appointment ScheduleConditionMedications(s) / Treatment(s) PrescribedDentist Name First Last PhoneAddress Street Address City State / Province / Region Emergency NumberLatest Exam Date Specific ConditionRoutine Check-up? Yes NoAppointment ScheduleMedications(s) / Treatment(s) PrescribedOther Physician Name First Last PhoneAddress Street Address City State / Province / Region Emergency NumberConditionLatest Exam Date Appointment ScheduleMedications(s) / Treatment(s) PrescribedPsychologist Name First Last PhoneAddress Street Address City State / Province / Region Emergency NumberLatest Evaluation Date Appointment ScheduleRecommendationsCounselor Name First Last PhoneAddress Street Address City State / Province / Region Emergency NumberAppointment ScheduleBehavior Therapist Name First Last PhoneAddress Street Address City State / Province / Region Emergency NumberAppointment SchedulePhysical Therapist Name First Last PhoneAddress Street Address City State / Province / Region Emergency NumberAppointment ScheduleOccupational Therapist Name First Last PhoneAddress Street Address City State / Province / Region Emergency NumberConditionAppointment ScheduleSpeech Therapist Name First Last PhoneAddress Street Address City State / Province / Region Emergency NumberConditionAppointment ScheduleMedication ListsPrescribed MedicationFor each medication, please list the medication name, dosage, frequency, and purposeOver-the-counter MedicationFor each medication, please list the medication name, dosage, frequency, and purposeAdaptive EquipmentHas the individual experienced any falls in the last year? Yes NoPlease explain any fallsEquipmentReasonSupplierRent or Own?AgeMaintenance ScheduleEquipmentReasonSupplierRent or Own?AgeMaintenance ScheduleEquipmentReasonSupplierRent or Own?AgeMaintenance ScheduleEquipmentReasonSupplierRent or Own?AgeMaintenance ScheduleHousing / Residential History (Include habilitation/institutional settings)Current type of housingAgency sponsored? Yes NoAgency NameAgency ContactAgency PhoneDates of ResidenceLandlord NameLandlord PhoneRoommates?Reason for leavingPrevious type of housingAgency sponsored? Yes NoAgency NameAgency ContactAgency PhoneDates of ResidenceLandlord NameLandlord PhoneRoommates?Reason for leavingTransportation SupportsDescribe transportation used for daily activitiesDescribe transportation used for regular/weekly activitiesDescribe transportation used for occasional activitiesDescribe use of public transportationPreferencesRoommatesHousingHousing amenitiesLocationStaffingDesired Weekly ScheduleFor each day, please list desired time period and supports neededMondayTuesdayWednesdayThursdayFridaySaturdaySundayInformation for this intake provided by (names and relationships)Interviewer (name and title)Date completed Forms and PoliciesIndividual Information and Intake FormEmergency Medical InformationInformation Release Policy On Resolving Consumer Complaints
