Rehab on the Road, PSC

Forms

This information is kept secure and confidential. It is emailed directly to Rehab on the Road, PSC and saves you waiting time filling out paperwork. Please complete this page prior to coming to your initial appointment. We greatly appreciate your time and efforts in completing this form.

Patient Name: Last, First MI *
Address: *
City: *
State: *
Zip Code: *
Email Address:
Home Phone #: *
Cell Phone #:
Age:
Social Security #:
Date of Birth: *
Gender: *
Marital Status: *
Referred By:: *
Primary Insurance: *
Primary Insur Address: *
Policy Number: *
Group Number: *
Guarantor Name: *
Guarantor Date of Birth: *
Secondary Insurance if applicable: *
Secondary Insur Address:
Policy Number:
Group Number:
Guarantor Name:
Guarantor Date of Birth:
Primary Care Physician: *
Primary Care MD Phone #:
Work Comp Claim?:
Auto Accident Claim?:
Date of Injury?:
Lawyer/Case Mgr Name:
Lawyer/Case Mgr Phone #:
Reason for Being Seen?: *
Other Current Medical Problems?:
Past Surgical History:
Family History (anything run in the family)?:
Allergies?:
Current Medications (names, dosages, frequency):
Do you smoke?:
How much do you smoke?:
Do you drink alcohol?:
How much do you drink?:
House Structure:
Number of Steps at Entry:
Who Lives with you?:
Do you own any additional equipment?:
Do you use any additional equipment?:
Check those that apply	Manual Wheelchair
	Power Wheelchair
	Power Scooter
	Standard Walker
	Rolling Walker
	Quad Cane
	Single tipped Cane
	Tub/Shower Bench
	High Rise Toilet Seat
	Bedside Commode