Based on your condition or service to be provided, please fill out and bring these forms with you to your physical therapy appointment.

Amputee

• Amputee History of Present Illness Form
• Lower Extremity Functional Scale Form

Aphasia, Stroke and Dementia Speech-Language Pathology

• Communicative Effectiveness Survey
• Speech History of Present Illness Form

Bariatrics

• Lower Extremity Functional Scale Form
• History of Present Illness Form

Cancer Treatment

• Oncology History of Present Illness Form
• FACT-G Form

Lower Body Lymphedema

• Lymphedema History of Present Illness Form
• Lymphedema Life Impact Scale Form

Lower Body Physical Therapy

• Lower Extremity Functional Scale Form
• Lower Extremity History of Present Illness Form

Lymphedema

• Lymphedema History of Present Illness Form
• Neck Disability Questionnaire

Men’s Pelvic Health

• Prostatitis Symptom Index Form
• Pelvic Health History of Present Illness Form

Neck and Lower Back

• Neck Disability Questionnaire
• Low Back Disability Questionnaire
• Spine History of Present Illness Form

Neuro Occupational Therapy

• Neurology History of Present Illness Form
• Upper Extremity Functional Scale Form

Neuro Physical Therapy

• Neurology History of Present Illness Form
• ABC Scale Form

Swallow Speech-Language Pathology

• Eating Assessment Tool
• Speech History of Present Illness Form

TMJ

• Neck Disability Questionnaire
• History of Present Illness Form

Upper Body Lymphedema

• Lymphedema History of Present Illness Form
• Upper Extremity Functional Scale Form

Upper Body Physical Therapy and Occupational Therapy

• Upper Extremity History of Present Illness Form
• Upper Extremity Functional Scale Form

Vestibular/Concussion

• Dizziness Handicap Inventory
• Vestibular History of Present Illness Form

Voice Speech-Language Pathology

• Voice Handicap Index Form

Wheelchair Evaluation

• Wheelchair Evaluation History of Present Illness Form

Women’s Pelvic Health

• Pelvic Health History of Present Illness Form
• Pelvic Floor Distress Inventory Questionnaire