PRE-VISIT INTAKE QUESTIONNAIRE
Who referred you?
If referred by a specific physician, mental health care provider, or other specialist, please provide
his/her name, specialty and contact information below:
Have you noticed any of these additional symptoms? Please check those that apply to you.
Please indicate if you are independent or need help with any of the following.
Getting from bed to chair
Getting to the toilet
Using the telephone
Taking your medicines
Managing money / financial
Doing “handyman” tasks
Getting to places beyond walking