Patient Forms

We would like to make your appointment as easy as possible. Please take your time filling out these forms. If you have questions in regards to which form to fill out please call us!

New Patient Intake Packets

Patient Intake Packet- Occupational/Physical Therapy

Patient Intake Packet- Pelvic Floor Physical Therapy (Females Only)

Patient Intake Packet- Pelvic Floor Physical Therapy (Males Only)

Patient Intake Packet- Pediatric Occupational Therapy

Forms

COVID-19 Informed Consent & Wellness Screening

Authorization to Release Medical Records

Patient Request for Medical Records

No Show/Cancellation Policy Form

Informed Consent Laser Therapy

Laser Medical History

Notice of Privacy Practices

Physical Therapy Outcome Measure

Lower Extremity Function

Neck Disability Index

Modified Oswestry Disability Scale

Shoulder Pain & Disability Index

Dizziness Handicap Inventory

Occupational/Hand Therapy Outcome Measure

Pelvic Floor Outcome Measures

Pelvic Floor Distress

Pelvic Floor Impact Questionnaire- PFIQ

Initial Vulvar Pain Functional Questionnaire (V-Q)

Queensland Female Pelvic Floor Questionnaire

NIH- Chronic Prostatitis Symptom Index (Males Only)

Lymphedema Outcome Measure

Lymphedema Life Impact Scale- LLIS

Questions? 360-279-8323

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