MEDICAL HISTORY
Referral Source(Doctor/therapist)___________________________________
Phone__________________________
How did you hear about the program?________________________________
________________________________________________________________
HEALTH HISTORY
Diagnosis________________________________________________________
Date of Onset___________________
Please indicate current or past special needs in the following areas:
AREAS AFFECTED please check areas of concern
Vision ____
Hearing ____
Sensation ____
Communication____
Heart ____
Breathing ____
Digestion ____
Elimination ____
Circulation ____
Emotional/Mental health ____
Behavioral ____
Pain ____
Bone/Joint ____
Muscular ____
Thinking/Cognition ____
Allergies ____
MEDICATIONS(include prescription, over-the-counter; name,
dose and frequency)____________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Describe your abilities/difficulties in the following areas
(include assistance required or equipment needed)
PHYSICAL FUNCTION(i.e.Mobility skills such as transfers, walking,
wheelchair,driving/bus riding)_______________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
PSYCHO/SOCIAL FUNCTION (i.e. Work/school including grade completed,
leisure interests, relationships-family structure, support systems,
companion animals, fears/concerns,
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
GOALS (i.e.Why are you applying for participation?
What would you like to accomplish?)________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Signature: ______________________________ Date:__________________
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