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Downloads
I have made several forms
available to examine or to download. They are in Adobe PDF format.
After you download the desired form, open and print it using Adobe Reader.
Fill in the form(s) that you have printed out with a black pen - you will not be
able to fill them on your computer without a special application - and be sure
to sign each page. New
patients may appreciate the opportunity to streamline their first visit by
having most of their paperwork completed in advance.
If you do not already have Adobe
Reader, you can click on their icon to download a copy:
Instructions for selecting and
completing new patient forms:
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Each
form packet contains a “Functional Rating Index” form. When
completing this form, take care only
to circle whole number values of the descriptions that most |
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Each
form packet contains a page with a pain diagram and a device called a
“Quad Visual Analog [Pain] Scale.” The pain diagram is
self-explanatory. Use it to indicate the location and characteristics
of your current symptoms. |
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The
Quad VAS lines are to be completed with a single vertical line for each
description (now, worst this past week, least this past week, and average
this past week) placed somewhere along the line between the left side (no
pain) and the right side (worst pain imaginable). Here are two
examples: |
Mild to moderate pain might look something like this:
______|_____________________
Severe pain might look something like this: ________________________|___.
If
you want to describe the pain in more than one region, use more than one line
and place a brief indicator by the entry (i.e. "lb" for low back,
"n" for neck, "sh" for shoulder, etc.)
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The Standard New Patient Form
will serve for anyone’s purposes, but there are additional pertinent items
in the forms intended for some specific patient circumstances. Click
on one of the following to download the appropriate form:
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