Forms
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.
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.
- Medical History Questionnaire
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Registration
Information Form
Stroke Impact Scale
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. We will ask you questions about impairments and disabilities caused by your stroke, as well as how stroke has affected your quality of life. Finally, we will ask you to rate how much you think you have recovered from your stroke.
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.