Patient Forms

To assist you with getting the most out of your first visit to us, please fill out the patient forms below, and bring them with you to your first visit. For your first visit, please also bring along your insurance information, a photo ID, and your physician’s prescription for physical therapy (if you have one).

NEW Patient Intake

Past Medical History

Consent for Treatment

Cancellation / No Show Policy

Patient Payment Policy

FORMS PERTAINING TO INJURY/ISSUE – Please fill out the forms that are referring to the injury or issue you are having. Note: Please call 316-283-7187 if you have any questions.

Dizziness Handicap Inventory(DHI) -Example: vertigo

Lower Extremity Form- Example: legs, hips, knees, sciatica, feet ankles 

Modified Oswestry – Example: Back

Neck Disability Index – Example: Neck

Quick Dash Initial – Example: Upper Extremities such as shoulders, upper back, arms, fingers, elbows, wrists, torso, hands