Patient Intake Form Schedule date Patient Information First Name Last Name D.O.B: Gender: Weight: Height: Shoe size: Address: City: State: Zip code: PARENT/LEGAL GUARDIAN INFORMATION Last Name: First: Relationship: Primary Phone: Email: CLINICAL INFORMATION Diagnosis: Who referred you: Primary Physician: Facility: Phone: Last Visit: Therapist: Facility: Phone: INSURANCE INFORMATION 1 Primary Insurance: PrivateMedicadTricare Other: ID#: Group#: Phone#: 2 Secondary Insurance: PrivateMedicadTricare Other: ID#: Group#: Phone#: PATIENT MOBILITY INFORMATION Does the patient use any of the following assistive devices?NoneWheelchairStanderGait TrainerWalkerCrutches Does the patient currently use orthotics? YN If Yes, What Kind? Age of Device: Is the current device meeting patient’s current goals? YN If No, Please explain? MILESTONES & GOALS (please check all that apply) Patient is able to: Sit up independentlyCrawlPull to standCruiseInd. standingInd. stepsSquat to stand Independent walkingKick a ballRunWalk up stairsJumpWalk down stairsRun and stop Patient goals: Patient/Therapy goals: Orthotic device being requested or recommended (this helps us check benefits): Select OneAFOSMOStretching AFOToe Walking SideLeftRightBilateral AND / OR Wrist/HandElbowBack/SpineKnee Other:
