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In-take Forms

Please print and fill out all forms and bring with you to your initial appointment.

Form 1: Assignment of Benefits

Form 2: Patient Information Form

Form 3: Medical History Form

Form 4: Pain Diagram

Form 5: Medication Check List

Form 6: Notice of Privacy Practices Acknowledgement

Form 7: Standard Signature on File Form- Medicare Cap (patients with Medicare only)


Functional Limitation Questionnaires

Please print and fill out the questionnaire that pertains to the body part for which you will be treated in physical therapy**

For patients with low back pain
The Oswestry Low Back Pain Disability Questionnaire

For patients with neck pain
The Oswestry Neck Pain Disability Questionnaire

For patients with upper extremity pain/injury/dysfunction
Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire

For patients with lower extremity pain/injury/dysfunction
The Lower Extremity Functional Scale

For patients referred with dizziness or vestibular problems (please fill out all three)
Dizziness Handicap Index
Dizziness Questionnaire
Falls Efficacy Scale



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