New Patient Forms
All of the forms you will need to fill out before your initial appointment are provided here. You may either fill out, sign, and submit the forms online, or you may download, print, and fill out the forms to bring with you to your first appointment or scan and email back to us. If you prefer to fill them out at our office, please arrive about 15 minutes before your initial appointment to do so. Please be sure to fill out all 4 forms as well as any questionnaire you were instructed to complete when scheduling your first appointment.
Form to fill out, sign and submit online:
Forms to print, fill out, and bring to the office or scan and email back to us:
Assessment Questionnaires
We will use at least one of these forms to quantify the level of dysfunction you are currently experiencing to defend the medical necessity of the treatments when billing your insurance. Please select a form from the category that best fits your situation. Some categories have multiple forms, so you can choose the form that most accurately represents your specific limitations.
LOW BACK
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- Modified Oswestry Disability Scale
NECK
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- Neck Disability Index
UPPER EXTREMITY
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- Quick DASH (Disabilities of the Arm, Shoulder & Hand)
- Shoulder Pain and Disability Index
- Upper Extremity Functional Index
LOWER EXTREMITY
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- LE Functional Scale
BALANCE, FALLS, & UNSTEADINESS
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- ABC Scale (Activities-Specific Balance Confidence Scale)
- Falls Efficacy Scale
DIZZINESS & VERTIGO
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- Dizziness Handicap Inventory
HEADACHE
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- Headache Disability Index
GENERAL PAIN
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- Pain Disability Index
URINARY CONTINENCE / SEXUAL FUNCTION / PROSTATE HEALTH (MALES)
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- Urogenital Distress Inventory
- Chronic Prostatitis Symptom Index
- International Index of Erectile Dysfunction
URINARY CONTINENCE / SEXUAL FUNCTION / PELVIC FLOOR (FEMALES)
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- Pelvic Floor Distress Inventory
- Pelvic Floor Impact Questionnaire
- Effects of Pelvic Organ Prolapse and Incontinence On Sexual Function Questionnaire