Individual Intake Resources Individual Information and Intake Form Individual Information and Intake Form "*" indicates required fields Step 1 of 8 12% 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 Female Ethnic Origin* Primary Language Spoken* Birth Date* MM slash DD slash YYYY Marital Status* Single Married Divorced Widowed Preferred Religion* Case Manager Email PhonePets Yes No Please list all type of pets present in the home or location of serviceConsent Status Can give own consent (emancipated) Consent from guardian Guardians Yes No Type of Guardianship Effective Date MM slash DD slash YYYY 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 No Are there any Advance Directives currently in place? Yes No Please detail Advance Directives currently in place Family / Guardians / FriendsName First Last Relationship to Individual PhoneAddress Street Address City State / Province / Region ZIP / Postal Code Email Contact in Emergency? Yes No Contact When ...Name First Last Relationship to Individual PhoneAddress Street Address City State / Province / Region ZIP / Postal Code Email Contact in Emergency? Yes No Contact When ... Medical InformationDoes the individual experience seizures? Yes No Seizure typeAre the seizures controlled? Yes No Date of last known seizure MM slash DD slash YYYY Does the individual have allergies? Yes No List all allergies, including plants, medication, dietary, animals, perfume, etc.Date of latest physical MM slash DD slash YYYY Date of last TB Tine test MM slash DD slash YYYY TB Tine test results Date of last Hepatitis B test MM slash DD slash YYYY Hepatitis B test results Vaccination history and datesHepatitis A Hepatitis B Tetanus List 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 Tuberculosis List 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 surgery Habits and ActivitiesDo you use tobacco? Yes No What form of tobacco? How much tobacco? For how long have you used tobacco? Do you drink alcohol? Yes No Yes, in the past How many drinks per week? Do you, or have you ever used recreational drugs? Yes No Please describe you recreational drug useDo you get regular exercise? Yes No What kind of exercise?How often do you exercise? Daily More than 30 minutes, 3 times per week One or two times per week Please list any hobbies or leisure activitiesSexual HistoryMy sexual partners have been Male Female Both I've never been sexually active Have you had more than one sexual partner in the past year? Yes No Have you ever had a sexually transmitted disease? Yes No Please describe what and when Medical, Mental Health, and Health PractitionersPrimary Physician Name First Last PhoneAddress Street Address City State / Province / Region Emergency NumberDate of Latest Exam MM slash DD slash YYYY Appointment Schedule Medication(s) Prescribed Treatment(s) PrescribedOB/GYN Name First Last PhoneAddress Street Address City State / Province / Region Emergency NumberDate of Latest Exam MM slash DD slash YYYY Date of Latest Mammogram MM slash DD slash YYYY Date of Latest Pap smear MM slash DD slash YYYY Medications(s) / Treatment(s) PrescribedAppointment Schedule Psychiatrist Name First Last PhoneAddress Street Address City State / Province / Region Latest Exam Date MM slash DD slash YYYY Appointment Schedule Condition Medications(s) / Treatment(s) PrescribedNeurologist Name First Last PhoneAddress Street Address City State / Province / Region Latest Exam Date MM slash DD slash YYYY Appointment Schedule Condition Medications(s) / Treatment(s) PrescribedDentist Name First Last PhoneAddress Street Address City State / Province / Region Emergency NumberLatest Exam Date MM slash DD slash YYYY Specific Condition Routine Check-up? Yes No Appointment Schedule Medications(s) / Treatment(s) PrescribedOther Physician Name First Last PhoneAddress Street Address City State / Province / Region Emergency NumberCondition Latest Exam Date MM slash DD slash YYYY Appointment Schedule Medications(s) / Treatment(s) PrescribedPsychologist Name First Last PhoneAddress Street Address City State / Province / Region Emergency NumberLatest Evaluation Date MM slash DD slash YYYY Appointment Schedule RecommendationsCounselor Name First Last PhoneAddress Street Address City State / Province / Region Emergency NumberAppointment Schedule Behavior Therapist Name First Last PhoneAddress Street Address City State / Province / Region Emergency NumberAppointment Schedule Physical Therapist Name First Last PhoneAddress Street Address City State / Province / Region Emergency NumberAppointment Schedule Occupational Therapist Name First Last PhoneAddress Street Address City State / Province / Region Emergency NumberCondition Appointment Schedule Speech Therapist Name First Last PhoneAddress Street Address City State / Province / Region Emergency NumberCondition Appointment Schedule Medication 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 No Please explain any fallsEquipment Reason Supplier Rent or Own? AgeMaintenance Schedule Equipment Reason Supplier Rent or Own? AgeMaintenance Schedule Equipment Reason Supplier Rent or Own? AgeMaintenance Schedule Equipment Reason Supplier Rent or Own? AgeMaintenance Schedule Housing / Residential History (Include habilitation/institutional settings)Current type of housing Agency sponsored? Yes No Agency Name Agency Contact Agency PhoneDates of Residence Landlord Name Landlord PhoneRoommates? Reason for leaving Previous type of housing Agency sponsored? Yes No Agency Name Agency Contact Agency PhoneDates of Residence Landlord Name Landlord PhoneRoommates? Reason for leaving Transportation SupportsDescribe transportation used for daily activitiesDescribe transportation used for regular/weekly activitiesDescribe transportation used for occasional activitiesDescribe use of public transportationPreferencesRoommatesHousingHousing amenitiesLocation Staffing Desired Weekly ScheduleFor each day, please list desired time period and supports neededMondayTuesdayWednesdayThursdayFridaySaturdaySunday Information for this intake provided by (names and relationships)Interviewer (name and title) Date completed MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged. Forms and Policies Individual Information and Intake Form Emergency Medical Information Information Release Policy On Resolving Consumer Complaints
