INITIAL INTAKE FORM - Generic for Adults
Date of Referral: _______________
Name of Patient: ____________________________________ GENDER: ___ DOB: ___/___/____
Referred By : _________________________
Date of accident / onset of injury/disease: __________
Address: _____________________________________________________________________________
Telephone No ____________________________ Contact Person _____________________________
Primary Diagnosis and Presenting Conditions:
_____________________________________________________________________________
Precautions/ Medications:
_____________________________________________________________________________
Reason For Referral/ Treatment Prescription (Frequency and Duration)
_______________________________________________________________________
Equipment Currently Used: _________________________________________________________________
Name / Address/ Tel. of Physician:
_____________________________________________________________________________________
_____________________________________________________________________Prescription
Received: _____________________________________________________________________
IF MANAGED CARE CASE: Nurse to Contact After First Visit:
__________________________________________________________________________________
BILLING INFO: _____ NF
____WC
______ PRIVATE INSURANCE ____ AGENCY ___ P.P.
Social Security Number: __________________________________________
NAME OF CARRIER: _____________________________________________
ADDRESS:_____________________________________________________________________________
_____________________________________________________________________________________
Claim / Group or Authorization #
_____________________________________________________________________________________
_
Name of Insured if Other than Patient: _______________________________________________________
Assignment of Benefits Required? ____________________________________________________________
Terms/ Limits of Policy? ___________________________________________________________________
Authorization for Treatment Required? ________________________________________________________
Current Medications:
Additional Info:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
________________________________________________________________
EMERGENCY CONTACT # ____________________________________________
Initial Intake Form - Pediatrics
Today’s Date ___________________Referred by_____________________________
Child’s Name___________________ DOB________ Diagnosis__________________
Mother’s name__________________ Father’s name___________________________
Telephone @ home_______________ Work_______________ Cell_______________
Address______________________________________________________________
Pediatrician____________________ Telephone_______________________________
Insurance Company _____________ Dept of Ed __________E.I.P_________________
School _________________________Telephone ________Teacher_______________
Emergency Contact _____________________Telephone_________________________
GENERAL HEALTH HISTORY
Describe your pregnancy, labor, delivery______________________________________
____________________________________________________________________
Was your child  Full term  Premature Gestational Age _____Birth weight _______
Has your child ever been hospitalized? _______________________________________
Was your child  Breast fed  Bottle fed? Did child transition easily to solids_________
At what age did your child: Sit ______Crawl ____Walk ___Talk____________________
____________________________________________________________________
Who lives at home ____________Siblings ________Any developmental issues or illnesses in family
______________________________________________________________
Has your child ever been treated for?
 Asthma  Allergies
 Ear infections  Feeding Problems  Food hypersensitivities

Gastrointestinal Problems  Headaches
 Major illness or injury  Seizures
 Sensory or motor issues
 Sleep Problems  Other__________________________
Comments_____________________________________________________________
____________________________________________________________________
____________________________________________________________________
Has your child seen any of the following specialists?
 Developmental Pediatrician  Neurologist  Psychiatrist  Audiologist
 Occupational Therapist
 Physical Therapist  Speech and Language Therapist
 Neuropsychologist  Osteopath  Chiropractor  Homeopath  Nutritionist
 Psychotherapist  Special Educator
____________________________________________________________________
Areas of concern__________________________________________________________
____________________________________________________________________
Please Note: Your health information will be kept confidential. Any information that we collect
about you on this form will be kept confidential in our office.
_______________________ __________________ ____________________
Name of Parent/Legal Guardian
Signature
Date