Patient Forms

ALL PATIENTS – READ ONLY

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    HEALTH INFORMATION PRIVACY NOTICE

PLEASE PRINT THESE 2 FORMS:

FUNCTIONAL OUTCOME QUESTIONNAIRES FOR ORTHOPEDIC CONDITIONS

Please choose the Questionnaire that best matches your condition or area of pain. Bring the completed forms to your initial visit.

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    The Dizziness Handicap Inventory ( DHI )

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    ORAL HEALTH IMPACT PROFILE (TMJ)

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    The Upper Extremity Functional Index (UEFI) – Elbow/Arm

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    Fear-Avoidance Beliefs Questionnaire

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    Oswestry Low Back Pain Disability Questionnaire

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    The Lower Extremity Functional Scale

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    The Neck Disability Index

If you are being seen for Pelvic Floor, Incontinence, Pelvic Pain, Pregnancy or Post-Partum Rehab, please click on the links below to find the specific forms you will need to fill out prior to your appointment.

PELVIC FLOOR WEAKNESS/DYSFUNCTION

FEMALE PELVIC DYSFUNCTION

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    Female Pelvic Dysfunction Questionnaire

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    Pelvic Floor Distress Inventory Questionnaire

Includes diagnoses such as urinary Incontinence (stress, urgency, frequency, nocturia, irritative voiding), fecal incontinence, pelvic organ prolapse, uterine prolapse, cystocele, rectocele, pelvic relaxation.

FEMALE PELVIC PAIN

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    Female Pelvic Dysfunction Questionnaire

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    Pelvic Pain Questionnaire

Includes diagnoses such as female pelvic pain, dyspareunia, vulvodynia, s/p abdominal or pelvic surgery (eg. Hysterectomy, C-section, etc)

PREGNANCY OR POST-PARTUM CONDITIONS

Includes lumbosacral pain, sacrococcygeal/tailbone pain, pubic symphysis pain or separation, back pain, sacroiliac joint pain, hip pain, pelvic pain

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    Female Pelvic Dysfunction Questionnaire

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    Pelvic Pain Questionnaire

REFERRAL FORM

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    Print and take to your physician