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InTake Form
1. Patient information
Client name
Gender
Male
Female
Other
Date of birth
Marital status
Phone number
2. Contact person
Name of contact providing information
Relationship to patient
Phone number
3. Emergency contact
Name of contact person
Phone number
Relationship to patient
4. Collateral information
Relationship to patient
Phone number
City
Contact person
Phone number
5. Medical history
Past medical history (if known):
6. Service type
Services requested for HHA
Services requested for IHSN
Requested start date
Does client live alone?
Yes
No
If yes, lives with (Name)
Relationship to patient
Language(s) spoken
Translator needed
No
Yes
7. Referral
Reason for referral
Client
Family
Social Worker
Discharge Planner
Doctor
Insurance Co
Physician name
Specialty
Phone
Medical and / or nursing diagnosis (If known)
Medications (If known. Separate with commas)
8. Financial
Financing options
Self-Pay
Private Insurance
Other
9. Functional status (check all that apply)
Mobility
Chair bound
Bedbound
Needs assistance with
Ambulation
Transfers
Transfers
Assistive devices
Walker
Cane
W/C
Shower/tub chair
Commode
ADL’s and IADL’s (Check all that apply)
Dressing
Bathing
Grooming
Oral hygiene
Meal prep and cooking
Shopping
Cleaning
Transportation
Drives
Dependent on others
Vision
Glasses
Blind
Legally Blind
Hearing
HOH
Hearing aids
R ear L ear both
Speech
Difficulty speaking
Does not speak
Does not speak or understand English
10. Alert / Awake / Oriented ?
Select option
Yes
No
If no, explain
Does client experience memory loss?
Yes
No
Confusion
Forgetfulness
Is client incontinent?
Yes
No
Confusion
Forgetfulness
If yes, of
Urine
Bowels
Wears disposable
Does client currently have any services in place?
Yes
No
If yes, please explain
Pertinent information for level of care appropriateness
Notes/Comments
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