History Information Form

July 30, 2010, 5:38 pm

BACKGROUND INFORMATION
First Name:
Last Name:
Sex: (M or F)
Age:
Date of Birth:
Address:
Phone Number (No dashes or parentheses)
   
City:
State: (ex. NC, SC)
Zip Code: (5 digit)
Driver's License / Permit Number:
State (on license): (ex. NC, SC)
Expiration date:
Restrictions:
Referring Physician
Physician Address
Physician Phone
Medical Insurance Company:
Policy #:
With whom do you live:


MEDICAL HISTORY
Disability:
Onset:
Past Medical History:
Medications Currently Using (Please list how often you take each medicine.)

Have you ever had seizures? If so, when was the last time?
   

Are you currently taking medicine for seizure control? If so, what medication:
   


PHYSICAL ABILITIES
Describe any problems you have using your arms and hands:  
Describe any problems you have using your feet:  
How do you usually get around:
Manual Type:

Power Type:
     
Do you wear:
 
If you use any other type of adaptive devices, what is it?  
If you have spasticity, when and where?  


HEARING AND VISION
Do you wear hearing aids?
   
Do you wear:
Do you have any loss of vision?
   
 
   


*If you have had an eye or hearing exam since your illness or injury, please acquire a copy of the report prior to your evaluation.



DRIVING HISTORY
What are your total years of driving experience?
   
Have you driven since your illness/injury?
   
 
Have you had any accidents that were your fault in the last five years?
   
 
Have you had your license suspended or taken away?
   
 
Have you had any DWI/DUI convictions?
   
 
   
How often do you think you might drive?
   
What is the most frequent distance you plan on driving?
   
What is the longest distance you think you might drive?

What type of vehicle do you plan on driving? Year, make, model:
   
Other vehicle specifications?
Power Steering
Power Brakes
   
Have you tried to get in and out of this vehicle since your injury/illness?
How much assistance did you require?


EMERGENCY INFORMATION
Contact name:
Contact relationship:
Contact phone:
Contact address:
   
This form was completed by:

 

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