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| RICHMOND PHYSICAL THERAPY ASHLAND PHYSICAL THERAPY |
| ORTHOPEDIC AND SPORTS PHYSICAL THERAPY |
| PATIENT FORMS |
Want to take care of the necessary paperwork before you arrive? Download
and fill out the forms(1-4) below, then simply bring them with you to your first
appointment.
The receptionist and physical therapist will go over all the forms with you, so
fill them out to the best of your ability.
and fill out the forms(1-4) below, then simply bring them with you to your first
appointment.
The receptionist and physical therapist will go over all the forms with you, so
fill them out to the best of your ability.
1. Patient Form This form provides us with your personal and insurance information.
2. Medical History This form provides us with your a detailed history of your medical background and
information regarding your current problem.
3. Body Specific Questionnaire (CHOOSE ONE) These forms provide us with further detailed
information directly related to the body part we will be
treating.
A. Arm, Shoulder, Hand
B. Lower Extremities (knee, ankle, foot)
C. Back
D. Neck
4. Patient Responsibilities Outlines our office polices and patient
responsibilities.
5. Notice of Privacy Practices (TO READ ONLY - DO NOT PRINT)
2. Medical History This form provides us with your a detailed history of your medical background and
information regarding your current problem.
3. Body Specific Questionnaire (CHOOSE ONE) These forms provide us with further detailed
information directly related to the body part we will be
treating.
A. Arm, Shoulder, Hand
B. Lower Extremities (knee, ankle, foot)
C. Back
D. Neck
4. Patient Responsibilities Outlines our office polices and patient
responsibilities.
5. Notice of Privacy Practices (TO READ ONLY - DO NOT PRINT)
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