Office Patient Forms

New Patient Forms

Please print out and complete the forms below for Columbia Physical Therapy, P.C. Bring the completed forms, as well as your insurance cards and medication list. We ask that you arrive 15 minutes early to review these forms and your insurance coverage.

All New Patients Will Fill Out

• New Patient History -  Patient History
  

Complete ONE of These Forms Based On What We Will Be Treating You For

• Neck and upper-back pain -  Neck Index
• Lower-back pain - Back Index
• Upper-extremity arm pain - UEFI, NYS  Empire plan - DASH
• Lower-extremity leg pain - LEFS - Medicare or Medicare Replacement Plan - WOMAC
• Vertigo-dizziness - Dizziness Handicap Inventory 
• Pelvic Health - Pelvic Health - Patient Hx Form