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Section 1: Patient background Personal information (required) Name (required) Email Phone Address Address 2 City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Date of birth (required) Gender/pronouns Referring physician Hand dominance (required) Right-handed Left-handed Ambidextrous Do you have a drug, latex or adhesive allergy? If so, please identify in the field below. (required) What is your current occupation? (required) Briefly describe your main work tasks (example: manual labor, heavy lifting, repetitive work, computer work). List any hobbies or activities that you enjoy that involve hand use and may be affected by your condition (example: knitting, gardening, playing a musical instrument or sports). Do you have any cultural, spiritual, religious, or personal routine we should respect during your care? Please list prior treatments and, if applicable, the number of occupational therapy visits. Section 2: Diagnosis questions Medical History (please select all that apply). (required) Osteoarthritis Multiple Sclerosis Stroke Cancer Fractured/broken bone Sleep disturbances Falls Rheumatoid Arthritis Muscular disease Anxiety/depression Stress Diabetes Low vision Deaf/hard of hearing Fibromyalgia None of the above Other… Enter other… Please describe the cause of your injury: (required) Section 3: Authorization for video, audio, photography and text messaging I authorize the Western Michigan University Occupational Therapy Clinics to videotape, audiotape, and/or photograph evaluation and therapy sessions. I understand that these recordings may be used for the following purposes: Clinical Purposes:To assist with assessment, treatment planning, and monitoring progress. Educational Purposes:For classroom instruction and to support the education and professional training of occupational therapy students. I understand and acknowledge that:I may revoke this authorization at any time by submitting a written request. However, this revocation will not affect any recordings already made or used in reliance on this authorization.My decision to sign this consent will not affect my eligibility for treatment or services.I have the right to receive a copy of this authorization for my records.Information disclosed or shared under this authorization may be re-disclosed to others for the purposes stated above and may no longer be protected by federal privacy regulations. By signing below, I acknowledge that I have read and understand this consent form and voluntarily authorize the use of recordings as described. Signature (required) By entering your name in the signature field, you acknowledge and agree that this serves as your electronic signature. Date (required) I do not authorize video, audio, photography or text messaging Section 4: Authorization to Share Contact Information and Communicate with Students I authorize the primary therapist at the Western Michigan University Occupational Therapy Clinic to communicate with me using my preferred method of contact and to share my contact information with appropriate students for clinical purposes. Purpose of Disclosure: This authorization allows the clinic and its students to use my contact information to assist with assessment, treatment planning, and monitoring my progress. My Rights and Acknowledgments:I may revoke this authorization at any time by submitting a written request. Revoking this authorization will not affect any actions taken in reliance on it prior to the revocation.My decision to sign this form will not affect my eligibility to receive treatment or services.I have the right to receive a copy of this authorization for my records. By signing below, I acknowledge that I have read, understand, and voluntarily agree to this authorization. Your signature (required) By entering your name in the signature field, you acknowledge and agree that this serves as your electronic signature Today's date (required) Thank you for taking the time to fill out this intake form for the Grand Rapids Occupational Therapy Hand Clinic! Submit Leave this field blank
