Located on this page are forms that need to be completed prior to your first visit.  For your convenience, we have listed them below for you to download and complete at your leisure.  Completing these forms before visiting our office can save you 15-20 minutes on your first appointment.  In order to view these documents, you will need a PDF viewer.  If you do not have one, you can download Adobe Acrobat here for free.

Required forms for all patients (Download All 3):

Confidential Medical History Form

Privacy Form

Authorization Form

Medicare patients must also sign these forms:

Medicare Policy

Functional Outcomes Measures (Choose 1)
In addition, our office actively participates in outcome measures.  This allows us to track our own productivity and effectiveness as providers, as well as your progress through your treatment programs.  These are simple questionnaires completed by the patient and scored by your therapist.  You will be required to fill out at least one of the following forms:

Back Index
This is used for patients who have low back problems.  You may also have leg or buttocks problems associated with your low back symptoms.

Neck Index
This is used for patients who have neck or upper back problems.  You may also have shoulder or arm problems associated with your neck symptoms.

DASH Index (Disabilities of the Arm, Shoulder or Hand)
This is used for patients who have arm, shoulder, or hand problems.  This is not to be used if your arm problems are associated with the neck.  Instead, please use the Neck Index listed above.

LEFS Index (Lower Extremity Functional Scale)
This is used for patients who have hip, knee, leg, or ankle problems.  Or, if you are having problems walking due to weakness, pain, or numbness in the legs.  This is not to be used if your leg problems are associated with the low back.  Instead, please use the Back Index listed above.


If you have any questions while completing these forms, please call us at (570) 874-2125 or email us at







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