AAHC - Self Admit Intake Form
Please complete as much information as possible to assist us with providing prompt home health care services.
WATCH THIS QUICK TUTORIAL VIDEO ON HOW TO SELF-ADMIT FOR HOME CARE.
Please attach a prescription/referral for home health care from your physician to this form.
*
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Patient Name
*
First Name
Last Name
Address
*
Street Address - (No PO Boxes)
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Email
example@example.com
Home Phone
-
Area Code
Phone Number
Cell Phone
*
-
Area Code
Phone Number
Preferred Method of Contact
E-mail
Home Phone
Cell Phone
Marital Status
Single
Married
Divorced
Widowed
Employment
Employed
Unemployed
Disabled
Retired
Student
Primary Care Provider
Emergency Contact Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Relationship
Insurance Information
Name of Insurer
*
First Name
Last Name
Insurer Phone Number
-
Area Code
Phone Number
Subscriber Name
First Name
Last Name
Subscriber Date of Birth
-
Month
-
Day
Year
Date
Subscriber Relationship to Patient
Group Number
*
Policy Number
*
Medical History
Please check all the apply
None
Allergies
Anemia
Angina
Anxiety
Arthritis
Asthma
Atrial Fibrillation
Benign Prostatic
Hypertrophy
Blood Clots
Cancer
Cerebrovascular Accident
Cronary Artery Disease
COPD (Emphysema)
Crohn's Disease
Depression
Diabetes
Gallbladder Disease
GERD (Reflux)
Hepatitis C
Hyperlipidemia
Hypertension
Irritable Bowel Disease
Liver Disease
Migraine Headaches
Myocardial Infarction
Osteoarthritis
Osteoporosis
Peptic Ulcer Disease
Renal Disease
Seizure Disorder
Thyroid Disease
Do you use tobacco?
No
Daily
Weekly
Less
Former User
Do you use alcohol?
No
Daily
Weekly
Less
Former User
Caffeine use?
No
Daily
Weekly
Less
Former User
Are you currently taking prescription medication?
Yes
No
Prescribing Doctor's Name
First Name
Last Name
Prescribing Doctor's Phone
-
Area Code
Phone Number
Have you had any surgeries in the past 5 years?
Yes
No
Please specify:
Family history
Adopted
Alcoholism
Allergies
Asthma
ArthritisBlood Disease
CAD (Heart Attack)
Cancer
CVA (Stroke)
Depression
Developmental Delay
Diabetes
Eczema
Hearing Deficiency
Hyperlipidemia (High Cholesterol)
Hypertension (High Blood Pressure)
Irritable Bowel Disease
Learning Disability
Mental Illness
Tuberculosis
Obesity
Osteoarthritis
Osteoporosis
PVD
Renal Disease
Why you are seeking treatment?
*Your signature below indicates that the information you have provided above is truthful.
Date
-
Month
-
Day
Year
Date
Signature
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