Patient Forms to Assist You

Functional Capacity Forms

To assist your physical therapist in performing a thorough initial evaluation we ask all of our clients to fill out a functional capacity form specific to the body region you are being seen for. You can fill this out at the clinic when you arrive but make sure you arrive 10-15 minutes prior to your appointment time to do so. We respect our client’s time therefore filling out such forms prior to your appointment will help insure that we are able to start your evaluation at your scheduled time. Please see below the links we have in place for neck, back, lower extremity and upper extremity conditions.

• Lower Extremity Functional Scale
• The Neck Disability Index Questionnaire
• The Oswestry Back Pain Questionnaire
• Upper Extremity Functional Scale

New Client/Patient Forms

Please fill out your New Patient Intake Form, Insurance Information, Financial Agreement, and Medical History Intake forms prior to arriving at your scheduled initial evaluation appointment. This will give your FOC a chance to verify your insurance coverage, acquire insurance authorization for you care and pursue any additional medical documents that may assist your physical therapist in their examination (i.e. x-rays, MRI, or other pertinent medical imaging).

• New Patient – Notice of Privacy Practice Form
• New Patient Information Form Consent for Care
• New Patient Medical Screening Intake Questionnaire
• New Patient – HIPAA Acknowledgement
• Pain Rating Scale

New patients, please complete these forms before your visit. This will ensure a timely appointment that helps us focus on you, not your paperwork.