For Patients

Forms

Appointment Form

If you are coming in for a first visit or for a new injury/problem area, you may wish to print and fill out a consultation form. This will save you time when you arrive at the clinic.

Patient New Injury Form


Additional Forms

If you have been injured in a motor vehicle accident and are covered by MPI,  or if you were injured at work and are covered by WCB please fill out 2 of the following forms. This will save you time when you arrive at the clinic for your first appointment.

Your answers on each form will be compiled into a number score. When you are done treatment you will fill out the same forms again. The two number scores will be compared to measure your progress.

Please complete the "Pain Scale Form" and pick one more form that is most applicable to your injury. If you have more than one area of injury, please fill out an additional form that is most applicable.

These forms are intended to be printed out and filled in manually. Please bring your filled out form to your initial appointment. Once you have printed the form, simply close the browser window to view this page again.


Pain Scale Form

This form may be used for any area of injury.

Visual Analog Scale


Disabilities of the Arm, Shoulder and Hand Assessment Forms

This form should be completed if you have injured any area of your upper extremity.

Disability of the Arm, Shoulder and Hand


Lower Extremity Functional Scale

This form should be completed if you have injured any area of your lower body from your hip down.

Lower Extremity Functional Scale


Roland Morris Back Pain Questionnaire

This form should be completed if you have injured your back.

Roland Morris Back Pain Questionnaire


Neck Disability Index

This form should be completed if you have injured your neck.

Neck Disability Index


Click here for more information about your specific injury or condition.

Click here to find out how our treatment can help you.

Call 204-987-9222 or click here to contact us.