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Personal Information
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Preferred contact method (check all that apply)
Living Situation
Type of residence
Home accessibility features (check all that apply)
Emergency Contact
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Referring & Primary Care Provider
Previous Therapy History — Medicare Requirement
Federal Medicare requirement: please report any therapy received since January 1st of the current year.
Physical Therapy (PT) since January of this year?
Occupational Therapy (OT) since January of this year?
Home Health Care in the last 30 days?
Social History
Smoking status:
Alcohol use:
Form 1 of 11 · Next Step Rehab Patient Intake Suite · www.nextstep-rehab.com