Occupational Therapy Adult Case History Form

Steps:

Please fill out this form as completely as possible. The information will help us understand your present communication problem(s) and will aid us in planning appropriate testing procedures. ALL INFORMATION IS STRICTLY CONFIDENTIAL.

*PLEASE NOTE: AFTER COMPLETION, PLEASE RETURN THIS FORM, ALONG WITH ANY OTHER PERTINENT MEDICAL REPORTS (e.g. Hospital discharge summaries, Neurological reports) TO THE CENTER AT LEAST (1) WEEK BEFORE THE SCHEDULED EVALUATION.

Client Information

Client's First Name:	Middle Name:	Last Name:
Permanent Address:	City:	State:	ZIP Code:
Home Phone:	Work Phone:	Cell Phone:	E-Mail:
Date of Birth:	Sex: Male Female	Age:
Marital Status: Single Married Divorced Widowed
Ethinicity: African-American Asian Caucasian Hispanic/Latino Other
Employer:	Employer Phone:
Name of Spouse:
Spouse's Employer:	Employer Phone:
Combined Income: Less than $12,000 $12,000-$20,000 $20,000-$30,000 $30,000-$50,000 $50,000-$70,000 $70,000-$90,000 $90,000-$120,000 Over $120,000
How did you hear about us? Word of mouth Phone Book/Yellow Pages School System Internet Physician - Name: Other
Reason for Referral:
Briefly Describe Problem:

Gross and Fine Motor History

Please mark if you have a history or difficulty with any of the following; please comment on questions that you answered yes.

Symptoms	Never	Rarely	Frequently	Comments
Hand or arm weakness
Hand or arm pain
Difficulty with clothing fasteners
Difficulty getting dressed
Difficulty with bathing/getting out of shower
Trouble holding a pencil
Difficulty with writing
Difficulty with typing
Difficulty organizing your daily routine
Difficulty remembering your daily routine
Difficulty cooking
Loss of balance when walking around your house

Have you had previous occupational therapy services for the above problems?

Does the above problems/problem get in the way of doing your every day routines?

What are you hobbies/interests?