Get Rehabilitation Services Medical History Intake Form Name

Filling out the Rehabilitation Services Medical History Intake Form online is an essential step in receiving personalized care tailored to your needs. This guide provides clear instructions on how to complete each section of the form effectively.

Follow the steps to complete the online form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the designated editor.
2. Begin by entering your name in the designated field labeled ‘Name (print):’ followed by the current date in the ‘Date’ field.
3. In the first section, indicate any health conditions you have experienced by checking the appropriate boxes (e.g., diabetes, lung disease). If there are additional conditions not listed, write them in the ‘Other’ field.
4. Next, state whether you have undergone any surgeries by selecting ‘YES’ or ‘NO’. If yes, list the surgeries in the space provided.
5. Proceed to the medication section. Indicate if you are taking any medications by selecting ‘YES’ or ‘NO’. If yes, list the medications in the specified area.
6. Then, provide information about any allergies you may have. Again, select ‘YES’ or ‘NO’, and if yes, detail the allergies.
7. For those who identify as female, respond to the question regarding the possibility of pregnancy by selecting ‘YES’ or ‘NO’.
8. Next, describe any activities you find difficult due to your current condition in the specified field.
9. Indicate whether you have personal goals or expectations for therapy by selecting ‘YES’ or ‘NO’. If yes, describe them in the provided space.
10. Mention any religious or cultural concerns that might affect your treatment by selecting ‘YES’ or ‘NO’. If yes, provide an explanation.
11. Rate your current pain level on a scale from 0 to 10 in the corresponding field.
12. List any previous treatments you have received for your condition in the designated field.
13. Indicate any tests you have undergone related to your condition by describing them in the specified area.
14. Address the question regarding the Allow Natural Death (AND) Advance Directive by selecting ‘YES’ or ‘NO’ and provide any necessary details.
15. Final step: Provide your signature in the designated signature field to confirm the information provided is correct.
16. Once you have filled out all necessary sections, you can save changes, download, print, or share the completed form.

Complete your Rehabilitation Services Medical History Intake Form online today for tailored support.