To view and print our standard forms you will need Adobe Acrobat®Reader. If you do not have this software, click here to download a free version.
Biographical Information Inventory
The purpose of this questionnaire is to acquire information that may be very important in planning or modifying therapies during rehabilitation. The more we know about a person’s background before their injury, the easier it is for us to tailor our work to their interests, disposition and personality. Whatever information you provide becomes a confidential part of the patient record, to be used by professional staff (physicians therapists, nurses). Please be as accurate as possible, and take your time in filling out these forms. The information you provide will have a very important impact on our work. Please return this form to the Case Management Department.
Outpatient Registration Forms
To expedite the registration process , we suggest you print out the following forms, complete them prior to your arrival and bring them with you on the day of your first appointment.
Stroke Clinic Life Satisfaction Questionnaire
The purpose of this questionnaire is to evaluate how stroke has impacted your health and life. We want to know from your point of view how stroke has affected you.
For further information on Strokes, click here.
Patient Portable Profile
The patient profile is a snapshot of your medical history, insurance information, and other important emergency or healthcare information which you can carry with you and update as your medical history changes. You may take this with you when you visit your physician, the hospital and any other medical provider. The intent is to help you take responsibility for your care.
This free patient profile form may be used by anyone who would like a concise way to keep all of their medical information on hand. This form can assist in conveying your medical history to other healthcare providers. This form can also assist you in an emergency situation when you may not be able to convey information that may be vital to your health and safety to an ambulance crew, rescue squad or police or fire department.
Simply print out the form, fill out the information, and then place the form in a purse or wallet. We suggest placing a copy of the form on your refrigerator with a magnet, or give it to a relative.