Client Check in

Client Check-in Form
Date *

Month Day Year
Date
Your therapist *
Client Name *
Client Initials *
Client Report: since your last session, what are specific activities you have done to help yourself meet your goals? *

Check-in - indicate 0 - 10 (0 = low amount, 10 = high amount) *

Tobacco Use *

Yes No
Alcohol use per week: *

0 - 2 3 - 5 5+
Have you had a fall since your last visit: *

Yes No
Are you experiencing physical pain? *

Yes No
If yes, what is your pain level? (0 = low, 10 = high)
If yes, where does your body hurt?
Are you taking your medications as prescribed? *

Yes No
If no, please explain
Have your Medications/Vitamins/Supplements changed? *

Yes No
If yes, please provide the name of new medication, dosage, why it was prescribed, and the name of the prescribing physician.
Do you feel safe at home? *

Yes No
If no, please explain.
Area(s) I want to focus on today *
Should be Empty:

Client Check-in Form