Please click on each form (blue text with bullet point links below) to download and print. Complete the printed forms specific to you and bring them with you to your first visit. Most of these forms are required for insurance claims processing purposes. **Please be sure to also bring your driver’s license, all medical insurance cards, and the prescription for physical therapy if issued one (a prescription for physical therapy is required for all workers’ compensation covered patients).
NOTE: These forms will work best with the latest version of Adobe Reader.
The following forms are required for all patients:
If you are considering Telehealth (live, synchronous audio and video session performed remotely), the following form is also required before initiating a Telehealth session:
The following forms (Forms 1-5 with blue links below) are symptom specific, so please select exactly two of the following 5 forms below which are most appropriate for your condition as described in the following:
If you are experiencing any neck/shoulder/arm/elbow/forearm/hand symptoms, please fill out the Neck Disability Index (Form 1 ) below AND the QuickDASH (Form 3) below.
If you are experiencing any back/hip/thigh/knee/leg/ankle/foot symptoms, please fill out the Modified Oswestry Disability Scale (Form 2) below AND the Lower Extremity Functional Scale (Form 4) below.
If you are experiencing dizziness/vertigo/falls/impaired balance, please fill out the Dizziness Handicap Inventory (Form 5) below AND the Neck Disability Index (Form 1) below.
Form 1 Neck Disability Index – Initial
Form 2 Modified Oswestry Disability Scale – Initial
Form 3 QuickDASH – Initial
