As a convenience, we are happy to provide the following forms on our website.
First-Time Patient Forms
Please complete the following two forms prior to your first appointment. These are required as they are your consent for treatment, as well as our cancellation policy, your authorization for release of medical records and your financial and insurance responsibilities:
Informed Consent Form
Online Version / Print Version (choose one, online preferred)
Medical History Questionnaire
Online Version / Print Version (choose one, online preferred)
Dry Needling Forms
Online Version / Print Version
Outcome Measure Forms
Please complete the following at your therapist’s request.
Male Prostatitis Symptoms Index
Online Version / Print Version (choose one, online preferred)
Female Prostatitis Symptoms Index
Online Version / Print Version (choose one, online preferred)
Vulvar Pain Index
Online Version / Print Version (choose one, online preferred)
Constipation Index
Online Version / Print Version (choose one, online preferred)
Female Sexual Function Index
Online Version / Print Version (choose one, online preferred)
Oswestry Disability Index
Online Version / Print Version (choose one, online preferred)
Pelvic Floor Disability Index (PFDI-20)
Online Version / Print Version (choose one, online preferred)
Initial Pelvic Pain Inventory
Online Version / Print Version (choose one, online preferred)
Pelvic Pain Goal Inventory Status
Online Version / Print Version (choose one, online preferred)
Pelvic Floor Inventory Questionnaire (PFIQ-7)
Online Version / Print Version (choose one, online preferred)
