Get Hospital Intake Form

Filling out the Hospital Intake Form online is a critical step in ensuring you receive appropriate care tailored to your needs. This guide will provide detailed instructions on how to complete each section of the form seamlessly.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the designated online editor.
2. Begin by entering your patient name in the appropriate field. This should reflect your full legal name as it appears on official documents.
3. Fill in your age and date of birth (DOB) accurately, as this information is essential for your medical records.
4. Provide the date of your next medical appointment. This helps the healthcare provider plan your ongoing care.
5. Indicate whether you are receiving any home health services by selecting 'Yes' or 'No'. This information is important for your rehabilitation plan.
6. State your employment status by selecting 'Yes' or 'No'. If employed, you will need to answer whether you plan on returning to work.
7. If applicable, briefly describe the type of work you do. This will help caregivers understand your daily activities and requirements.
8. List any pertinent medical history, including surgeries and dates, in the designated space. This helps the medical team provide informed care.
9. Respond to questions about difficulties with eating or swallowing, recent weight changes, visual or hearing impairments, and history of falls. Provide explanations where required to clarify your circumstances.
10. Indicate whether you feel safe at home and if you have any fears regarding returning home, elaborating where necessary.
11. If you have experienced domestic violence or abuse, please answer truthfully, as this will inform your care.
12. Answer whether you were able to care for yourself prior to your current injury or illness and specify if you currently need assistance.
13. Concisely list your rehabilitation goals, as these will guide your treatment program.
14. Finally, sign and date the form to confirm the information is accurate. Ensure this does not become part of your permanent medical record.

Complete your documents online today for a smoother healthcare experience.