Home Health Agency New Patient / Client Intake & Health History Form | Editable Word + PDF | US Letter + A4 | Instant Download

Home Health Agency New Patient / Client Intake & Health History Form — an editable Word + PDF template built for non-medical home care and home health agencies, care managers, and schedulers.

This template collects registration details, practice-specific questions (insurance or treatment goals), a check-box health history, medications and allergies, current concerns, and a signed acknowledgment. Open it in Word or Google Docs, replace the bracketed placeholders with your name, logo, prices, and terms, and it's ready to use.

★ SAVE 56% WITH THE BUNDLE ★
This template is $9.99 on its own. The Home Health Agency Forms Bundle gives you all 8 Home Health Agency templates — New Patient / Client Intake & Health History Form, Financial Policy, Treatment Consent & Photo Release, Cancellation & No-Show Policy, Daily Opening & Closing Checklist, Appointment Confirmation, Reminder, No-Show & Recall Message Templates, Front Desk SOP, Daily Task List & Phone Scripts, Feedback Survey & Review Request Form, Supply Inventory & Order Checklist — for $34.99 instead of $79.92 bought separately.
👉 Get the bundle: https://www.etsy.com/pt/listing/4570717197/home-health-agency-forms-bundle-8
👉 Or the Home Health Agency Complete Practice Kit — 12 templates for $69.99 (45% off): https://www.etsy.com/pt/listing/4570732616/home-health-agency-complete-practice-kit

WHAT YOU GET (instant download, ZIP file)
• Editable Microsoft Word file (.docx) — US Letter
• Editable Microsoft Word file (.docx) — A4
• Print-ready PDF — US Letter
• Print-ready PDF — A4
• Quick-start README with editing instructions and license

WORKS WITH
Microsoft Word, Google Docs, Apple Pages, LibreOffice. No Canva or special software needed.

WHY THIS ONE
• Written specifically for home health agency work — not a generic form with the name swapped
• Plain-language wording your patients and clients can actually read
• Clean, professional layout with a header block for your logo and contact details
• Fill-in fields, tables, checklists, and signature lines already laid out

COMPLETE YOUR HOME HEALTH AGENCY PAPERWORK
Every Home Health Agency template in our shop shares the same layout, header block and wording, so your intake, estimate, invoice and agreement look like one system. Bundle: https://www.etsy.com/pt/listing/4570717197/home-health-agency-forms-bundle-8
Complete kit: https://www.etsy.com/pt/listing/4570732616/home-health-agency-complete-practice-kit

PLEASE NOTE
• This is a digital download; nothing will be shipped.
• Colors may vary slightly between screens and printers.
• Templates are for use in your own business and may not be resold or redistributed.
• Not legal or medical advice: review agreements, policies, and consent forms with a qualified professional and adapt to your local laws before use.
• Designed by TradeDocsStudio with the help of AI tools and reviewed by a human before listing.

Due to the digital nature of this product, refunds are not available — but if anything is wrong with your files, message us and we'll fix it.