Get Intake Sheet Form

Completing the Intake Sheet Form is an essential step in ensuring that your rehabilitation program meets your individual health needs. This guide provides clear instructions to navigate the form effectively and efficiently.

Follow the steps to fill out the Intake Sheet Form online.

1. Click ‘Get Form’ button to obtain the Intake Sheet Form and open it in an online editor.
2. Begin by filling out your personal information. Enter your last name, first name, and middle initial. Then, provide your complete address, including street address, city, state, and zip code. Don't forget to enter your date of birth and your age.
3. Next, input your email address for communication purposes, as well as the names and phone numbers of your emergency contact, referring physician, and primary physician.
4. In the insurance section, provide the name of your insurance provider and the co-payment amount that will be due on the date of service.
5. Articulate the reason for your referral to the program in your own words. This section helps the clinicians tailor the program to your needs.
6. List all prescribed and over-the-counter medications you currently take, including the dosage and frequency. If you already have a list prepared, you may attach it instead.
7. Indicate any allergies you have in the designated field. This information is crucial for your safety during the rehabilitation program.
8. Answer the question regarding an Advanced Directive or Durable Power of Attorney. If applicable, indicate whether you would like information about these documents.
9. Reflect on any cultural, spiritual, or religious beliefs that may influence your learning process during the rehabilitation program, and provide details in the designated section.
10. Complete the Review of Systems section by checking 'Yes,' 'No,' or 'Not Sure' for each medical condition listed. If you answer 'Yes,' please provide an explanation in the comments section.
11. Detail any previous surgeries with their respective years and locations in the provided fields.
12. Describe any daily activities you can no longer perform due to your cardiac condition and state your goals for what you hope to achieve from the program.
13. Finally, read the Declaration of Commitment. Sign and date the form to confirm your willingness to participate in the rehabilitation program.
14. Once you have filled out all sections, review the information for accuracy. You can then save your changes, download a copy, print the form, or share it as needed.

Start filling out your Intake Sheet Form online today to take the first step toward a healthier you.