INTAKE FORM. Name: Relationship: Home Phone: Work Phone: Cell Phone: Name: Phone: Address: City: State: Zip Code: Name: Phone:

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Hilary Joseph
5 years ago
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1 INTAKE FORM Please read and carefully complete the following. It is very important that you provide complete and accurate information because your responses will be relied upon in creating and providing an aquatic program tailored to your personal physical condition, restrictions and goals. If any information is not disclosed, or is not accurately disclosed, you may not receive the safest and best aquatic program. Also, if your condition changes at any time, please immediately notify Summers Aquatic Therapy & Fitness, LLC, in writing so that this Intake Form and your aquatic program can be updated and modified. Notification of any change is very important before any session begins. Thank you. Date: Name: General Information Address: City: State: Zip Code: Home Phone: Work Phone: Cell Phone: Date of Birth: Marital Status: Height: Weight: Sex: Handedness: Emergency Contact: Name: Relationship: Home Phone: Work Phone: Cell Phone: Referral Source (if applicable): Name: Phone: Address: City: State: Zip Code: Primary Care Physician: Name: Phone: Other Health Practitioners: Name: Specialty: Phone: Name: Specialty: Phone:

2 Name: Specialty: Phone: Health History Are you currently pregnant? YES/NO Please list any health problems/injuries for which you are seeking treatment/date of onset: Known cause of injury: YES/NO Cause: Have you had any imaging (x-rays, an MRI, CT scan, Bone Density Scan) done? YES/NO Please indicate the imaging type/ body part/ date of findings: Please list any surgeries or hospitalizations/dates: Have you ever been treated for this injury before? YES/NO If so, what was your treatment? What was the result of treatment? What things make your condition better? What things make your condition worse?

3 Is your pain more or less during various times of day? Please describe: Is your condition limiting of your daily activities/recreation? Please list all medications that you take: Please list any allergies/reactions: Please Indicate the intensity of your pain at rest: (No Pain) (Worst pain imaginable) Please indicate the intensity of your pain with movement: (No Pain) (Worst pain imaginable)

4 Please mark the diagram below to indicate where you feel the following sensations: P = Pain N = Numbness, T = Tingling, B = Burning,, ST = Stiffness, A=Aching Past Medical History: (circle all that apply) Sensory and Vestibular Frequent ear infections Vestibular dysfunction Hearing impairments Hearing Aids Visual Impairments Neurological Seizures Stroke Traumatic Brain Injury Spinal Cord Injury Autonomic Dysreflexia Hypotonia Multiple Sclerosis Fibromyalgia Complex Regional Pain Syndrome Cognitive Dementia Orthopedic Weight bearing restriction Range of motion restriction Osteoporosis Osteoarthritis Rheumatoid Arthritis Pulmonary COPD Asthma Use of supplemental O2 Cardiovascular Cardiomyopathy Myocarditis Heart Attack/Myocardial Infarction Congestive Heart Failure Hypertension/high blood pressure Low blood pressure

5 DVT/Blood clot Orthostatic Hypotension Chest pain Communicable Disease Hepatitis A Hepatitis B Hepatitis C Cryptosporidium Ecoli Giardia Shigella Cdiff MRSA HIV Tuberculosis Fever>100 degrees Vomiting in past 24 hours Athletes foot Bowel/Bladder Bladder incontinence Active Urinary Tract Infection Recurrent Urinary Tract Infections Bowel incontinence without stool program Diarrhea within last 2 weeks Colostomy Ileostomy Urostomy Indwelling urinary catheter Metabolic Dialysis Diabetes Pregnancy Heat Sensitivity Unexpected weight loss Unexpected weight gain Cancer Night sweats Night pain Integumentary Open wound/cut Psoriasis Eczema Other health problems: Mobility Status Do you use? Cane Crutches Walker Wheelchair/Scooter Braces/Splints Orthotics Exercise: Days/Week: Length of workouts: Type(s) of activity: What is your goal for aquatic therapy?

6 Pool Information Please circle one: Private Pool, Community Pool Community Pool Rules/Regulations that may apply: Pool description: Size: Available Depths: Average Temperature: Chemicals utilized: Pool Accessibility: (Circle all that apply) Stairs Ramp Railing Mechanical Lift Do you need assistance getting in/out of the pool? YES/NO Do you have any exercise/therapy equipment for the pool? Are you able to swim? YES/NO What is your level of comfort with being in the water? (Circle all that apply) Fearful, Anxious, Comfortable, Love the Water Other:

7 Is there any additional information you would like Summers Aquatic Therapy & Fitness to know? I represent and warrant that I carefully read and reviewed this entire Intake Form and that the information provided is complete and accurate. I understand and acknowledge that the information I provided will be relied upon by Summers Aquatic Therapy & Fitness, LLC and that any errors or inaccuracies in the information I provide could result in me not receiving the best aquatic therapy and fitness program and could also result in harm to my health or condition. I agree to immediately notify Summers Aquatic Therapy & Fitness, LLC of any change in the responses to this Intake Form and especially before the start of any therapy session. Date: / / Signed:

INTAKE FORM. Name: Specialty: Phone: Name: Specialty: Phone:

INTAKE FORM. Name: Specialty: Phone: Name: Specialty: Phone: INTAKE FORM Please read and carefully complete the following. It is very important that you provide complete and accurate information because your responses will be relied upon in creating and providing