Initial Patient Intake Form Logo

  • Initial Patient Intake Form

  • Ethos Physical Therapy

    Plymouth
    44191 Plymouth Oaks Blvd. Suite 800
    Plymouth, MI 48170    		 South Lyon
    515 N. Mill Street
    South Lyon, MI 48178

     

     (734) 463-3007 | ethosptmi.com

  • Patient Intake Questionnaire

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  • Treatment

  • Patient Forms & Consent

  • Medical History

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  • No Show Policy

  • Lower Extremity Pain / Injury

  • LEFS - INITIAL VISIT

  • Description: This survey is meant to help us obtain information from our patients regarding their current levels of discomfort and capability.

    Please select the answers below that best apply.

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  • Source: Binkley et al (1999): The Lower Extremity Functional Scale (LEFS): Scale development, measurement properties, and clinical application. Physical Therapy.

    79:371-383.

  • Upper Extremity Pain / Injury

  • QuickDASH - Initial

  • INSTRUCTIONS

    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 circling the appropriate number. If you did not have the opportunity to perform an activity in the past week, please make your best estimate of 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.

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  • QuickDash © Institutes for Work and Health, 1996, All rights reserved.

  • Neck Pain / Injury

  • Description: This survey is meant to help us obtain information from our patients regarding their current levels of discomfort and capability.

    Please select the answers below that best apply.

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  • NECK DISABILITY INDEX - INITIAL VISIT

  • Back Pain / Injury

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  • Description: This survey is meant to help us obtain information from our patients regarding their current levels of discomfort and capability.

    Please select the answers below that best apply.

  • ODI © Jeremy Fairbank 1980, All rights reserved. ODI contact information and permission to use: MAPI Research Trust, Lyon, France. E-mail: contact@mapi-trust.org – Internet: www.mapi-trust.org

  • Acknowledge & Submit

  • Patient Signature:

  • Parent / Guardian Signature:

  • Clear
  • Should be Empty: