Intake Form Client Name * First Name Last Name Date of Birth * MM DD YYYY Currently at * Home Skilled Nursing Facility Hospital Shelter Other Current Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Email Medicare Number * Medi-cal Number Social Security Number * Income Source * Retirement SSI SSDI None Other Total Monthly Income * Responsible Party If applicable First Name Last Name Phone (###) ### #### Email Significant weight loss? * Yes No Diarrhea? * Yes No Nausea? * Yes NO Increased Confusion? * Yes No Trouble sleeping? * Yes No Any recent hospitalizations? * Yes No Recent falls? * Yes No Shortness of breath? * Yes No Chest Pain? * Yes No Dizziness? * Yes No Ambulation? * Walks independently Cane Walker Wheelchair Needs help transferring to and from bed? * Yes No Hearing? * Good Fair Poor Deaf Vision? * Good Fair Poor Blind Cognitive Ability? * Alert Fairly Alert Dementia/Alzheimer's Weight * Height * # of Meds Daily * Balance? * Good Fair Poor Wound? * None Stage 1 Stage 2 Stage 3 Stage 4 Other Podiatry Needs? Yes No Check all that apply * Medical condition and history Muscle Weakness Neuropathy CHF Multiple Sclerosis History of Falls Dizziness Diabetes Muscular Dystrophy Arthritis Osteoporosis Amputee Cancer Family History Cancer Parkinson's History of Stroke Impaired Speech Paralysis HIV/Aids Edema Smoke Cigarettes Asthma Hypertension COPD Use Oxygen Dialysis Alcohol/Drug Use Injectable Medications Incontinence Catheter Quadriplegia Paraplegia Schizophrenia Psychosis Bi Polar Depression Aggressive Behavior Check all that apply * Assistance with Daily Living (ADLs) Independent with ADLs Grooming Medication Management Needs Special Transportation Transportation/Errands Lifting Bathing Meal Preparation Light Housekeeping Verbal Cues/Redirection Companionship Dressing Transferring Toileting Eating Thank you!
