New Patient Intake Form
After scheduling your first appointment with us, we will email you an “intake invitation” for you to complete prior to the first appointment. The intake will allow you to input all of your necessary information as well as upload images of your insurance cards, physician prescriptions, medication lists, etc. If you will be using insurance, the intake will also provide questionnaires to complete based on which conditions you select for which you are seeking treatment. These questionnaires are important in establishing sufficient medical necessity to support insurance claims.
Returning Patient Assessment Questionnaires
Insurance companies typically require a reassessment every 10th session to continue to establish the medical necessity of treatment. Below you will find a list of questionnaires categorized by condition. Unless we have requested an additional form, you only need to select the same form(s) used for your first session.
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