Please Click on a Link Below to Download a Copy of the Appropriate Form

Physician Referral Form

FYZICAL Prescription Form
FYZICAL Prescription Form.pdf
Adobe Acrobat document [203.4 KB]

New Patients MUST Bring the New Patient Forms and at Least One

of the Following Special Test Forms to Their First Appointment.

New Patient Forms

FYZICAL New Patient Forms
Patient Information & Medical History
FYZICAL New Patient Forms.pdf
Adobe Acrobat document [194.7 KB]

Special Test Forms

FYZICAL Quick Dash Form
Fill Out This Form for Problems with the Arms, Shoulders and/or Hands
FYZICAL Quick Dash Form.pdf
Adobe Acrobat document [364.2 KB]
FYZICAL Lower Extremity Functional Scale
Fill Out This Form for Problems with the Hips, Legs, Knees, Ankles and/or Feet
FYZICAL LEFS Form.pdf
Adobe Acrobat document [293.9 KB]
FYZICAL Neck Disability Index
Fill Out This Form for Problems with the Neck
FYZICAL NDI Form.pdf
Adobe Acrobat document [674.7 KB]
FYZICAL Oswestry Disability Index
Fill Out This Form for Problems with the Back
FYZICAL ODI Form.pdf
Adobe Acrobat document [664.3 KB]
FYZICAL Falls Efficacy Scale
This Form is REQUIRED for All Medicare Patients (Fall Risk Factor)
FYZICAL Falls Efficacy Scale Form.pdf
Adobe Acrobat document [132.4 KB]
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