All of our intake forms are provided through our Patient Portal, which you can access at: https://foundationalconcepts.janeapp.com/login.
For your convenience, we’ve also included printable versions of the forms below. These can be used for initial review or as a backup if needed, though we do prefer that all forms be submitted online.
First-Time Patient Forms
Please complete the following two forms before your first appointment. These are required and serve as your consent for treatment, acknowledgment of our cancellation policy, authorization for the release of medical records, and agreement to financial and insurance responsibilities.
Informed Consent Form
Medical History Questionnaire
Outcome Measure Forms
Please complete the following at your therapist’s request.
Dry Needling Forms
Male Prostatitis Symptoms Index
Female Prostatitis Symptoms Index
Vulvar Pain Index
Constipation Index
Female Sexual Function Index
Oswestry Disability Index
Pelvic Floor Disability Index (PFDI-20)
Initial Pelvic Pain Inventory
Pelvic Pain Goal Inventory Status
Pelvic Floor Inventory Questionnaire (PFIQ-7)
Lower Extremity Functional Scale
Discharge
