The Patient Registration Form is required for all new patients on their first visit to Orthopedic Physical Therapy, Inc.
You may also find specific forms and questionnaires below that apply to your diagnosis or problem. Please print and fill out the appropriate forms prior to your initial office visit.
- Patient Registration Form (required)
- Medical Services Agreement
- Dry Needling Consent Form
- Referring Event Form
- General Orthopedic History Form
- General TMJ History Form
- TMD Pain Questionnaire
- Female NIH Chronic Prostatitis Symptom Index
- Female Pelvic Floor Intake & Objective Evaluation Questionnaire
- Male Pelvic Floor Intake Questionnaire
- Male Chronic Prostatitis System Index
- Bowel Questionnaire
- Neck Disability Index Form
- Disabilities of the Arm, Shoulder, and Hand Questionnaire
- Lower Extremity Functional Scale Form
- Oswestry Back Pain Disability Questionnaire
- Fear Avoidance Beliefs Questionnaire
- NFRS Pain Scale
- ICIQ UI Short Form Questionnaire
- Custom Orthotics Policy
- CSI Inventory Worksheet
Please call Orthopedic Physical Therapy, Inc. at (804) 285-0148 with any questions about the new patient registration form or our questionnaires.
Online Patient Resources
‘Time to Treat Men Right‘ – An article about Pelvic Dysfunction by ADVANCE for Physical Therapy and Rehab Medicine
Read the Washington Post’s new article, ‘Myofascial Pain Syndrome often leaves doctors baffled and patients untreated‘
Radio Interview Excerpts:
Listen to Dr. Tracey Adler on the The Professionals Round Table with Michael David on Empire Radio Now
Dr. Adler is interviewed by Gloria Taylor Edwards and Shirley T. Burke on the “Speaking from the Heart” Radio Show – WCLM Radio 1450AM. The topic of their discussion was “The Magic of Dry-Needling“. Click on the links below to listen.
Radio Show, Part 1, Radio Show, Part 2