FORMS:
You may download and fill out the needed forms prior to your visit or wait until your visit to fill them out.
New Patient Intake Form
Upper Extremity Problem
- Download and fill out this form if you are being seen for any problem dealing with your shoulder, arm, wrist and/or hand.
Lower Extremity Problem
- Download and fill out this form if you are being seen for any problem dealing with your Hip(s), thigh, Legs, Ankles, Feet &/or Toes
Back Pain Questionnaire
- Download and fill out this form if you are being seen for any problem dealing with your Back and/or if you have sciatic type pain in your leg.
Neck Pain Questionnaire
- Download and fill out this form if you are being seen for any problem dealing with your Neck and/or if you have pain referred into your arm, hand and/or fingers.
Forms related to Balance, Vertigo &/or Dizziness
ABCScale
- The Activities-specific Balance Confidence (ABC) Scale*. Determines your level of confidence in doing the activity without
losing your balance or becoming unsteady.
Fall Efficacy Scale
- Assess fear of falling
Dizziness Handicap Inventory (DHI)
- Identifies difficulties that you may be experiencing because of your dizziness.
Home Environment
- Helps you assess how safe your home is; weather you are at risk of falling due to your home environment.
Vertigo Symptom Scale
- Assess frequence and severity of dizziness symptoms within the last 12 months.
Dizziness Rating Sheet
- Rates the intensity of your dizziness.
Stay Independent
- Questions to help you stay / maximize your independence.
Vestibular Patient Medical History Questionnaire
- Provides important information to help the Doctor determine the nature of your Vestibular / Dizziness and/or Balance problems.