New Patient Appointment

Clinic and Problem Area

Please select the area of your body you want to be seen for and the clinic you would like your requests sent to: (These choices will affect the forms below)

Problem Area

Simple Appointment Request

Whether you are new or have been treated at OrthoSports before and wish to request an appointment, please provide your contact information. We will contact you by phone or email to schedule an appointment.

You may also call one of our locations to request an appointment.

New Patients: To save you time, you may fill out the necessary forms below - which you would otherwise receive in person at one of our clinics.

Printable forms are available.

New Patient Forms

Fill out and submit the forms below and you will be all set for your first visit. Someone at OrthoSports will contact you by phone to schedule an appointment if you do not already have one.

If you have any questions or problems, please contact us.

Problem Area

Neck Index

This questionnaire will give your provider information about how your neck condition affects your everyday life. Please answer every section by selecting the one statement that applies to you. If two or more statements in one section apply, please select the one statement that most closely describes your problem.

Pain Intensity

I have no pain at the moment.

The pain is very mild at the moment.

The pain comes and goes and is moderate.

The pain is fairly severe at the moment.

The pain is very severe at the moment.

The pain is the worst imaginable at the moment.

Personal Care

I can look after myself normally without causing extra pain.

I can look after myself normally but it causes extra pain.

It is painful to look after myself and I am slow and careful.

I need some help but I manage most of my personal care.

I need help every day in most aspects of self care.

I do not get dressed, I wash with difficulty and stay in bed.

Sleeping

I have no trouble sleeping.

My sleep is slightly disturbed (less than 1 hour sleepless).

My sleep is mildly disturbed (1-2 hours sleepless).

My sleep is moderately disturbed (2-3 hours sleepless).

My sleep is greatly disturbed (3-5 hours sleepless).

My sleep is completely disturbed (5-7 hours sleepless).

Lifting

I can lift heavy weights without extra pain.

I can lift heavy weights but it causes extra pain.

Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned (e.g. on a table).

Pain prevents me from lifting heavy weights off the floor, but I can manage light to medium weights if they are conveniently positioned.

I can only lift very light weights.

I cannot lift or carry anything at all.

Reading

I can read as much as I want with no neck pain.

I can read as much as I want with slight neck pain.

I can read as much as I want with moderate neck pain.

I cannot read as much as I want because of moderate neck pain.

I can hardly read at all because of severe neck pain.

I cannot read at all because of neck pain.

Driving

I can drive my car without any neck pain.

I can drive my car as long as I want with slight neck pain.

I can drive my car as long as I want with moderate neck pain.

I cannot drive my car as long as I want because of moderate neck pain.

I can hardly drive at all because of severe neck pain.

I cannot drive my car at all because of neck pain.

Concentration

I can concentrate fully when I want with no difficulty.

I can concentrate fully when I want with slight difficulty.

I have a fair degree of difficulty concentrating when I want.

I have a lot of difficulty concentrating when I want.

I have a great deal of difficulty concentrating when I want.

I cannot concentrate at all.

Recreation

I am able to engage in all my recreation activities without neck pain.

I am able to engage in all my usual recreation activities with some neck pain.

I am able to engage in most but not all my usual recreation activities because of neck pain.

I am only able to engage in a few of my usual recreation activities because of neck pain.

I can hardly do any recreation activities because of neck pain.

I cannot do any recreation activities at all.

Work

I can do as much work as I want.

I can only do my usual work but no more.

I can only do most of my usual work but no more.

I cannot do my usual work.

I can hardly do any work at all.

I cannot do any work at all.

Headaches

I have no headaches at all.

I have slight headaches which come infrequently.

I have moderate headaches which come infrequently.

I have moderate headaches which come frequently.

I have severe headaches which come frequently.

I have headaches almost all the time.

Neck Index Score

Back Index

This questionnaire will give your provider information about how your back condition affects your everyday life. Please answer every section by selecting the one statement that applies to you. If two or more statements in one section apply, please select the one statement that most closely describes your problem.

Pain Intensity

The pain comes and goes and is very mild.

The pain is mild and does not vary much.

The pain comes and goes and is moderate.

The pain is moderate and does not vary much.

The pain comes and goes and is very severe.

The pain is very severe and does not vary much.

Personal Care

I do not have to change my way of washing or dressing in order to avoid pain.

I do not normally change my way of washing or dressing even though it causes some pain.

Washing and dressing increases the pain but I manage not to change my way of doing it.

Washing and dressing increases the pain and I find it necessary to change my way of doing it.

Because of the pain I am unable to do some washing and dressing without help.

Because of the pain I am unable to do any washing and dressing without help.

Sleeping

I get no pain in bed.

I get pain in bed but It does not prevent me from sleeping well.

Because of pain my normal sleep is reduced by less than 25%.

Because of pain my normal sleep is reduced by less than 50%.

Because of pain my normal sleep is reduced by less than 75%.

Pain prevents me from sleeping at all.

Lifting

I can lift heavy weights without extra pain.

I can lift heavy weights but it causes extra pain.

Pain prevents me from lifting heavy weights off the floor.

Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned (e.g. on a table).

Pain prevents me from lifting heavy weights off the floor, but I can manage light to medium weights if they are conveniently positioned.

I can only lift very light weights.

Sitting

I can sit in any chair as long as I like.

I can only sit in my favorite chair as long as I like.

Pain prevents me from sitting more than 1 hour.

Pain prevents me from sitting more than 1/2 hour.

Pain prevents me from sitting more than 10 minutes.

I avoid sitting because it increases pain immediately.

Traveling

I get no pain while traveling.

I get some pain while traveling but none of my usual forms of travel make it worse.

I get extra pain while traveling but it does not cause me to seek alternate forms of travel.

I get extra pain while traveling which causes me to seek alternate forms of travel.

Pain restricts all forms of travel except that done while lying down.

Pain restricts all forms of travel.

Standing

I can stand as long as I want without pain.

I have some pain while standing but it does not increase with time.

I cannot stand for longer than 1 hour without increasing pain.

I cannot stand for longer than 1/2 hour without increasing pain.

I cannot stand for longer than 10 minutes without increasing pain.

I avoid standing because it increases pain immediately.

Social Life

My social life is normal and gives me no extra pain.

My social life is normal but increases the degree of pain.

Pain has no significant affect on my social life apart from limiting my more energetic interests (e.g. dancing, etc).

Pain has restricted my social life and I do not go out very often.

Pain has restricted my social life to my home.

I have hardly any social life because of the pain.

Walking

I have no pain while walking.

I have some pain while walking, but it doesn't increase with distance.

I cannot walk more than 1 mile without increasing pain.

I cannot walk more than 1/2 mile without increasing pain.

I cannot walk more than 1/4 mile without increasing pain.

I cannot walk at all without increasing pain.

Changing degree of pain

My pain is rapidly getting better.

My pain fluctuates but overall is definitely getting better.

My pain seems to be getting better but improvement is slow.

My pain is neither getting better or worse.

My pain is gradually worsening.

My pain is rapidly worsening.

Back Index Score

Disabilities of the Arm, Shoulder, and Hand

This questionnaire asks about your symptoms as well as your ability to perform certain activities.

Please answer every question, based on your condition in the last week, by selecting the appropriate number.

If you did not have the opportunity to perform an activity in the past week, please make your best estimate on which response would be the most accurate.

It doesn't matter which hand or arm you use to perform the activity; please answer based on your ability regardless of how you perform the task.

Please rate your ability to do the following activities in the last week by selecting the number below the appropriate response.
NO DIFFICULTY MILD DIFFICULTY MODERATE DIFFICULTY SEVERE DIFFICULTY UNABLE
1. Open a tight or new jar. 1 2 3 4 5
2. Write. 1 2 3 4 5
3. Turn a key. 1 2 3 4 5
4. Prepare a meal. 1 2 3 4 5
5. Push open a heavy door. 1 2 3 4 5
6. Place an object on a shelf above your head. 1 2 3 4 5
7. Do heavy household chores (e.g. wash walls, wash floors). 1 2 3 4 5
8. Garden or do yard work. 1 2 3 4 5
9. Make a bed. 1 2 3 4 5
10. Carry a shopping bag or briefcase. 1 2 3 4 5
11. Carry a heavy object (over 10 lbs). 1 2 3 4 5
12. Change a lightbulb overhead. 1 2 3 4 5
13. Wash or blow dry your hair. 1 2 3 4 5
14. Wash your back. 1 2 3 4 5
15. Put on a pullover sweater. 1 2 3 4 5
16. Use a knife to cut food. 1 2 3 4 5
17. Recreational activities which require little effort (e.g. cardplaying, knitting, etc). 1 2 3 4 5
18. Recreational activities in which you take some force or impact through your arm, shoulder, or hand (e.g. golf, hammering, tennis, etc). 1 2 3 4 5
19. Recreational activities in which you move your arm freely (e.g. playing frisbee, badminton, etc.). 1 2 3 4 5
20. Manage transportation needs (getting from one place to another). 1 2 3 4 5
21. Sexual activities. 1 2 3 4 5
NOT AT ALL SLIGHTLY MODERATELY QUITE A BIT EXTREMELY
22. During the past week, to what extent has your arm, shoulder, or hand problem interfered with your normal social activities with family, friends, neighbours or groups? 1 2 3 4 5
NOT LIMITED AT ALL SLIGHTLY LIMITED MODERATELY LIMITED VERY LIMITED UNABLE
23. During the past week, were you limited in your work or other regular daily activities as a result of your arm, shoulder, or hand problem? 1 2 3 4 5

Please rate the severity of the following symptoms in the last week.
NONE MILD MODERATE SEVERE EXTREME
24. Arm, shoulder, or hand pain. 1 2 3 4 5
25. Arm, shoulder, or hand pain when you performed any specific activity. 1 2 3 4 5
26. Tingling (pins and needles) in your arm, shoulder, hand. 1 2 3 4 5
27. Weakness in your arm, shoulder, or hand. 1 2 3 4 5
28. Stiffness in your arm, shoulder, or hand. 1 2 3 4 5
NO DIFFICULTY MILD DIFFICULTY MODERATE DIFFICULTY SEVERE DIFFICULTY SO MUCH DIFFICULTY THAT I CAN'T SLEEP
29. During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder, or hand? 1 2 3 4 5
STRONGLY DISAGREE DISAGREE NEITHER AGREE NOR DISAGREE AGREE STRONGLY AGREE
30. I feel less capable, less confident or less useful because of my arm, shoulder, or hand problem. 1 2 3 4 5
Score

The Lower Extremity Functional Scale

We are interested in knowing whether you are having any difficulty at all with the activities listed below because of your lower limb problem for which you are currently seeking attention. Please provide an answer for each activity.

Today, do you or would you have any difficulty at all with:

Activities Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty
1 Any of your usual work, housework, or school activities. 0 1 2 3 4
2 Your usual hobbies, recreational or sporting activities. 0 1 2 3 4
3 Getting into or out of the bath. 0 1 2 3 4
4 Walking between rooms. 0 1 2 3 4
5 Putting on your shoes or socks. 0 1 2 3 4
6 Squatting. 0 1 2 3 4
7 Lifting an object, like a bag of groceries from the floor. 0 1 2 3 4
8 Performing light activities around your home. 0 1 2 3 4
9 Performing heavy activities around your home. 0 1 2 3 4
10 Getting into or out of a car. 0 1 2 3 4
11 Walking 2 blocks. 0 1 2 3 4
12 Walking a mile. 0 1 2 3 4
13 Going up or down 10 stairs (about 1 flight of stairs). 0 1 2 3 4
14 Standing for 1 hour. 0 1 2 3 4
15 Sitting for 1 hour. 0 1 2 3 4
16 Running on even ground. 0 1 2 3 4
17 Running on uneven ground. 0 1 2 3 4
18 Making sharp turns while running fast. 0 1 2 3 4
19 Hopping. 0 1 2 3 4
20 Rolling over in bed. 0 1 2 3 4
Score
Health History
Have you recently been ill, hospitalized, or had surgery?

Please provide dates and descriptions:
Do you have a pacemaker?
Besides dental work or a pacemaker, do you have any metal implanted in your body?
Where?
Have you had any recent weight loss or gain (over 15 pounds)?
Do you have allergies?

Please describe:
Do you smoke?
How much?
Do you drink alcoholic beverages?
How much?
Check if you have or have had any of the following conditions:
Allergies Anemia Anxiety Arthritis
Asthma Autoimmune Disorder Cancer Cardiac Conditions
Cardiac Pacemaker Chemical Dependency Circulation Problems Currently Pregnant
Depression Diabetes Dizzy Spells Emphysema/Bronchitis
Fibromyalgia Fractures Gallbladder Problems Headaches
Hearing Impairment Hepatitis High Cholesterol High/Low Blood Pressure
HIV/AIDS Incontinence Kidney Problems Metal Implants
MRSA Multiple Sclerosis Muscular Disease Osteoporosis
Parkinsons Rheumatoid Arthritis Seizures Smoking
Speech Problems Strokes Thyroid Disease Tuberculosis
Vision Problems Chest Pain Shortness of Breath Extreme Fatigue
Poor Quality Sleep Night Pain Peripheral Vascular Disease Gout
Neurological Disorder Stomach Problems Lupus Eating Disorder

Other:

Have you experienced an injury as a result of a fall in the past year?
Have you experienced two or more falls in the last year?
List any regular exercise activity:
List any medications you are currently taking:
Date of last eye exam?
Date of last comprehensive physical?
Females: Date of last gynecological exam?
Patient Information
PATIENT NAME SEX AGE BIRTHDATE

(MM/DD/YYYY)
PERMANENT ADDRESS CITY, STATE, ZIP
HOME PHONE BUSINESS PHONE EMAIL
SOCIAL SECURITY #
RELATIONSHIP OF RESPONSIBLE PARTY TO PATIENT
RESPONSIBLE PARTY NAME (if indicated) RESPONSIBLE PARTY DATE OF BIRTH
RESPONSIBLE PARTY SOCIAL SECURITY #
PATIENT MARITAL STATUS PATIENT EMPLOYMENT STATUS
EMPLOYER NAME
EMPLOYER ADDRESS EMPLOYER PHONE
SPOUSE OR NEAREST RELATIVE'S NAME
SPOUSE OR NEAREST RELATIVE'S ADDRESS SPOUSE OR NEAREST RELATIVE'S PHONE
DATE OF INJURY IF INJURY RELATED TO ACCIDENT, WHAT TYPE?
LEGAL PROCEEDING PENDING? SHOULD REPORT BE SENT TO ATTORNEY?
WHAT PART OF YOUR BODY IS INVOLVED? WHICH SIDE OF YOUR BODY?
REFERRING PHYSICIAN HOW DID YOU HEAR ABOUT US?
PRIMARY INSURANCE
INSURANCE NAME INSURANCE ADDRESS
POLICY HOLDER NAME POLICY HOLDER SEX POLICY HOLDER BIRTHDATE RELATIONSHIP TO PATIENT
ID # GROUP/CLAIM #
SECONDARY INSURANCE
INSURANCE NAME INSURANCE ADDRESS
POLICY HOLDER NAME POLICY HOLDER SEX POLICY HOLDER BIRTHDATE RELATIONSHIP TO PATIENT
ID # GROUP/CLAIM #
Consent

As a courtesy to our patients, OrthoSports Physical Therapy will bill your primary insurance carrier. Upon receipt of payment from your insurance company, the allowed balance will be transferred to you. While we accept most insurance, payment amounts vary based on your specific plan. We suggest that you contact your insurance carrier to determine what is covered for physical therapy services by your plan.

Co payments are due at the time of service. If you have to cancel your appointment, do so in 24 hours in advance. Should you cancel on the same day or not attend a scheduled appointment there will be a $40 charge for the missed visit.

An itemized billing statement of the services provided to you is available at anytime per your request. Please ask the receptionist, therapist, or you may call the billing office at 602-315-9762.

I have read and fully understand OrthoSports Physical Therapy's notice of Information Practices. I understand that OrthoSports Physical Therapy may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluation of the quality of services provided and any administrative operations related to treatment or payment. I understand that I have the right to restrict how my personal health information is used and disclosed for treatment, payment, and administrative operations if I notify the practice. I also understand that OrthoSports Physical Therapy will consider requests for restriction on a case by case basis, but does not have to agree to the request for restrictions.

I hereby consent to the use and disclosure of my personal health information for purposes as noted in OrthoSports Physical Therapy's Notice of Information Practices. I understand that I retain the right to revoke this consent by notifying the practice in writing at any time.

CONSENT FOR TREATMENT: I understand that I have the right to ask and have any questions answered prior to receiving treatment, including any risks or alternatives to the treatment plan that has been prescribed for me. By choosing a payment option and signing this form, I consent to have an OSPT physical therapist provide treatment.

PLEASE CHOOSE ONE OF THE FOLLOWING PAYMENT OPTIONS:

I understand that insurance claims will be submitted to my insurance companies as a matter of convenience. If there should be a third party payer, OrthoSports Physical Therapy has the right to bill my full-billed charges to that payer. I also understand and agree that I am ultimately responsible and liable for payment of all charges assessed for professional services rendered and will pay any sum due upon demand.

I hereby assign my insurance benefits to OrthoSports Physical Therapy for services rendered until my authorization is rescinded.

SIGNED - Patient or Guardian:

(Type name below)

DATE: 05/26/2018

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