Download Forms
This page contains links to downloadable patient information forms. Some of these forms are used to provide your physical therapist with the information needed to make a proper evaluation and develop an effective treatment plan; others are necessary for prompt insurance reimbursement filing.
Clinical Evaluation Forms
These questionnaires provide important diagnostic information. Please download, print, and complete the questionnaire that best corresponds to your pain or injury. If you aren’t sure which one is appropriate for you, please call the clinic at (408) 358-6505. We’ll be happy to assist you.
DASH Questionnaire (arm, shoulder, hand) (.pdf)
Foot/Ankle Disability Index (.pdf)
Hip Condition (.pdf)
Lower Extremity Functional Scale (.pdf)
Lysholm Knee Scoring Scale (.pdf)
Neck Disability Index (.pdf)
Oswestry Low Back Pain Questionnaire (.pdf)
Shoulder Function Assessment (.pdf)
First Visit Forms
These forms are required for your first visit:
Patient Information Form (.pdf)
Patient Information Record (.pdf)
Consent Form (.pdf)
Financial Contract (.pdf)
Credit Card Letter (.pdf)
You may also wish to download and print our one-page map and directions to the clinic (.pdf).
