Intake Forms

For your first appointment

Please Complete The General Health Screen form and sign the HIPAA acknowledgment after reading the HIPAA privacy notice.

• General Health Screen

• HIPAA acknowledgment

• HIPAA privacy notice (read-only; there is no need to print them)

Injury Specific Form

Please also select one and fill out a form that relates to your specific condition

• Neck pain (Neck Disability Index)

• Back pain (Oswestry Disability Questionnaire)

• Shoulder pain (Shoulder Pain and Disability Index)

• Arm pain (Disabilities of the Arm Shoulder and Hand Questionnaire)

• Leg pain (Lower Extremity Disability Scale)

• Ankle pain (Functional Foot Index)