Pre-Visit Forms

Tell Us About Your Symptoms

The more we understand about how you’re feeling, the better we can tailor a treatment plan for you. That’s why we use forms to learn more about your symptoms and how they are affecting your life. The more we know, the more we can accomplish during your appointment. Your health is important, and we want to make the most of your time with us.

Please complete any forms that describe the symptoms or issues you are experiencing. You should fill out one copy of each form and bring the completed forms with you to your appointment with us.

Dizziness

Feeling dizzy or unsteady can make it hard to do the things you love. Tell us about your symptoms.

• Dizziness Handicap Inventory (DHI) (PDF)

Headaches

We know that headache pain can be different for everyone. Help us understand more about your headaches.

• Headache Disability Index (HDI) (PDF)

Lower Back Pain

Share information about when you’re having lower back pain.

• Low Back Self-Assessment (PDF)

Lower Extremity Pain

Tell us more about the issues you’re having with your hips, legs, knees, ankles or feet.

• Lower Extremity Functional Scale (LEFS) (PDF)

Neck Pain

Is neck pain getting in the way? Help us understand how the pain is affecting your daily life.

• Neck Self-Assessment (PDF)

Shoulder Pain

Is shoulder pain making it hard for you to get dressed or lift heavy things? Tell us about your symptoms.

• Shoulder Pain and Disability Index (SPADI) (PDF)