Her Health Physical Therapy, LLC

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New Patient Paperwork

Please download and complete your New Patient Paperwork prior to arriving at your Initial Evaluation. If you are unsure as to which paperwork to complete please feel free to give us a call, and we will be happy to assist you. Otherwise, please read the explanations below and click on the link that leads to the appropriate documentation. 

 **NOTE: These documents are to be downloaded, printed (one-sided please!) and filled out for your initial appointment. They cannot be submitted online! Thank You.


Patients with Orthopedic conditions:

If your Initial Evaluation will be for an incident related to any orthopedic issue (back, knee, neck, etc.) please click the link below to download your New Patient Paperwork:

Orthopedic Patient Paperwork (PDF)

Along with the above paperwork, Insurance also now requires you to complete one of the following questionnaires:

Neck Pain

Low Back Pain

Shoulder/Elbow/Arm Pain

Knee/Leg Pain

Foot/Ankle Pain

Diastasis Recti


Patients with Women's Health conditions: 

If your Initial Evaluation will be for an incident related to any Women's Health issue (pelvic pain, incontinence, pain with intercourse, etc.) please click the link below to download your New Patient Paperwork:

Women's Health Patient Paperwork (PDF)


Along with the above paperwork, Insurance also now requires you to complete one of the following questionnaires:

- Do you have pelvic pain, pain with intercourse, pain with sitting, and/or Symphysis Pubis Disorder? Please complete BOTH of the following questionnaires:

V-Q

&

Pelvic Girdle


- Do you have organ prolapse and/or urinary or fecal incontinence? Please fill out the following questionnaire:

Pelvic Floor Distress Inventory


Men's Health Patients: 

If your Initial Evaluation will be for an incident related to any Men's Health Issue (i.e. pelvic pain, incontinence, difficulty with urination/defecation, pain with sitting) please click the link below to download your New Patient Paperwork:

Men's Health Patient Paperwork (PDF)

Along with the above paperwork, Insurance also now requires you to complete the questionnaires below:

- Do you have pelvic pain and/or Prostatitis? Please complete BOTH of the following questionnaires:

Male NIH Symptom Index (NIH-CPSI)

&

Pelvic Girdle