Forms and Registration

The Patient Registration Forms are 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 Forms (required for all)
• Medicare Patient Information (required for Medicare patients only)
  
• Orthopedic History Form
• General TMJ Intake Forms
• Patient Attestation Form

Pain Scales

• Activities-Specific Balance Confidence (ABC) Scale
• CSI Inventory Worksheet
• Disabilities of the Arm, Shoulder, and Hand Questionnaire
• Fear Avoidance Beliefs Questionnaire
• Lower Extremity Functional Scale Form
• Neck Disability Index Form
• NFRS Pain Scale
• Oswestry Back Pain Disability Questionnaire
• TMD Pain Questionnaire

Other Forms

• Custom Orthotics Policy
• Dry Needling Consent Form
• Referring Event Form
• Scoliosis New Patient Packet
• Vestibular Intake Form

Please call Orthopedic Physical Therapy, Inc. at (804) 285-0148 with any questions about the new patient registration form or our questionnaires.