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Modal Box

This is a sample modal box that can be created using the powers of CSS3.

You could do a lot of things here like have a pop-up ad that shows when your website loads, or create a login/register form for users.

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Forms

Patient Forms

Thank you for choosing Summit Physical Therapy to provide you with rehabilitation services. We want to ensure that your first visit is as smooth as possible and that all of your questions are answered. To help us better serve you, please bring the following to your appointment:

  •   Photo ID
  •   Current insurance card(s) (or information related to your workers’ compensation or auto injury)
  •   Referral from your physician
  •   Any questions you might have for your therapist

You may also wish to print and complete the following paperwork prior to your visit to decrease your initial visit time.

History Forms

Subjective History – General

Subjective History – Pediatric

Subjective History – Pelvic Girdle

Subjective History – Speech

Adult

Subjective History – Speech, Child

Subjective History – Vestibular

Functional Outcome Tools

Arm, Shoulder, Hand – DASH

Arm, Shoulder, Hand – QuickDASH WorkSport

Arm, Shoulder, Hand – QuickDASH

Balance, Gait, Falls – ABC Scale

Barthel Index

Colorectal Distress Inventory

Fear Avoidance Questionnaire, Patients with Back Pain – FABQ

Foot and Ankle – FAAM Sport

Foot and Ankle – FAAM

Hand – HAT

Henry Ford Hospital Headache Disability Index

Hip Outcome Score, Daily Living – HOS ADL

Hip Outcome Score, Sports – HOS SOS

Incontinence Symptom Questionnaire

Knee – KOS ADL

Knee – KOS Sport

Low Back Pain – Modified Oswestry

Lower Extremity – LEFS

Neck Pain Disability Index

Pelvic Floor Impact

Prolapse Questionnaire

Prolapse Questionnaire

TMD Disability Index

Urinary Distress Index

Vestibular – DHI

Walking Scale – MSWS-12

Workers Comp Functional Baseline Questionnaire

Fill Out These Forms

before your visit to expedite your wait time!

(918) 342-3800