Date: __________ Patient name: __________________________
CareCentrix intake ID: ___________ Diagnosis:_______________
Question Reply or required information
Prior level of function?
Specific barriers to patient transitioning to outpt
If yes, what restriction
Is the patient homebound?
If yes, please explain (with specific parameters that makes them
Extremity weakness or paralysis
If yes, location
Current ambulation (in feet)
Is the patient using an assistive device?
If yes, what device (crutches, cane, walker, etc)
Does the patient require assistance to ambulate?
If yes, is it min, max or standby assist?
Does the patient need to negotiate stairs to reach the
bedroom/bathroom or exit the home?
Is the patient able to negotiate stairs independently? If no, what
type of assist is needed
Is there a home exercise program (HEP) in place?
Is the patient/family caregiver participating in the HEP?
What PT goals have been met
What PT goals are remaining
For Medicare Advantage patients, please answer the following:
If therapy is requested for balance and gait, please provide the
results of one objective test:
Timed up and go
Does the patient require assistance with transfers? If yes, what
type of transfers?
If yes, how much assistance is required? Min, standby or max
Number of visits requested: ______ Anticipated discharge date: ___________
Date range: _______________________________
CareCentrix Proprietary 2009