Intake Adult

MARITAL STATUS:

years.
Regarding your spouse or significant other, please provide the following information.
years.

FAMILY HISTORY:

(Please fill out even if they are deceased.)
Name Education Workplace Age
Mother
Father

BROTHERS AND SISTERS

Name Age Sex Occupation Highest Grade Achieved

CHILDREN

Name Age Sex Occupation or Grade Live at Home? Step Child?

EDUCATION INFORMATION:

Currently Enrolled
        last grade completed:

Were you ever enrolled in special education classes:
        No
        Yes
        If YES, please give details:
       
Did not complete High School
        last grade completed:
High School Diploma
Vocational training
        currently enrolled
        completed; Specialty:
Degree(s) earned:

EMPLOYMENT/VOCATIONAL:

PHYSICAL HEALTH INFORMATION:


  Date Reason Results
Last
Physical
Visit

MM/DD/YY
Last
Doctor
Visit

MM/DD/YY
Last
Dental
Visit

MM/DD/YY
Have you noticed any recent changes in:
Sleeping Patterns Behaviour
Eating Patterns Energy
Physical Activity Weight
Increased Tension Disposition
MEDICAL INFORMATION: Past and Present (Please Check any)
  No Past Present
Allergies
Asthma
Ulcer
Chronic Stomach
Heart Disease
Seizure/Epilepsy
Fainting/Dizzy
Hallucinations
High/Low Blood Pressure
High/Low Blood Sugar
Thyroid Problems
Liver Disease
Vision Problems
Hearing Problems
Broken Bones
Major Injuries
OB/GYN Problems
Diabetes
Communicable Diseases
Nutritional Problems
Other problems (specify): 
  Past   Present

Current Medication and Drug Use: (Include all drugs)

Name of Drug Prescribed? Dosage Frequency

Previous medication and/or drug usages (prescription and non-prescription)

Name of Drug Dosage Reason of Stoppage
Have you ever overdosed on a drug or medication?

RELATIONSHIPS:

Please briefly describe how you get along with:

PRIOR COUNSELLING/TREATMENT INFORMATION:

Have you ever received prior counselling, drug, or psychiatric services?

ALCOHOL/SUBSTANCE USE:

yrs. old.
Do you use alcohol regularly?
yrs. old.
Do you use other substances?
FOR WORKPLACE SAFETY INSURANCE BOARD CASES ONLY:

SUPPLEMENTAL INFORMATION

Is there anything else you consider important for us to know about yourself?
Name

CONSENT TO ASSESSMENT AND TREATMENT

Please read and agree to the Standard of Care for Dr. Svec Rehabilitation Clinics.