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Section 1: Patient background Personal information Name 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 Gender/pronouns Referring physician Hand dominance Right-handed Left-handed Ambidextrous What is your current occupation? 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? Yes No Other… Enter other… Section 2: Primary Diagnosis Questions Could you share the primary neurological condition you were diagnosed with? Please provide the date your condition started (include month and year). What are your primary goals for Occupational Therapy (i.e. improve use of hand, improve ability to walk, improve ability to dress, etc.) Could you describe any physical difficulties you experience, such as weakness, feeling unsteady or trouble moving your arms or legs as intended? Do you use a mobility device? Do you have any trouble communicating? Please list all medications you are currently taking. Do you have any allergies that we should be aware of? Please describe your pain, including location, if applicable Please rate your pain level. Questions 0 - No pain 2 - Hurts a little 4 - Hurts a little more 6 - Hurts even more 8 - Hurts a whole lot 10 - Hurts the worst Your pain level 0 - No pain 2 - Hurts a little 4 - Hurts a little more 6 - Hurts even more 8 - Hurts a whole lot 10 - Hurts the worst Please share information about your medical history that is important for us to know about. 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 By entering your name in the signature field, you acknowledge and agree that this serves as your electronic signature. Date 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. 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