For Patients

Patient Forms

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Download and Print Patient Forms

We encourage all new patients to come to their first therapy visit 15 minutes early with their new patient forms completed. For your convenience in downloading these forms, please click on the links below.

If you would prefer to download your forms and fill them all out by hand, the links below will allow you to do this. You will be required to complete your Privacy and Medications Statement upon arrival to the clinic.

Instructions:

On the Care Connections Functional Index (CCFI) worksheet, please fill in “Functional Index” and then the sections that pertain to the body part that you will be being seen for. On the backside of the document fill in the correct body parts as well and complete the “Pain Index” worksheet provided. The “Global Rating of Change” and the “Work Status” are used on your last visit.

New Patient Form

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Pelvic Floor Patient Form

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Vestibular Patient Form

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