New Patient Paperwork
To expedite your first visit and enhance the patient experience, you can print and fill out patient intake forms prior to arriving for your first visit. Please bring these forms with you as well as a copy of your insurance card and a list of current medications.
Forms for all patients:
Each patient should fill out one of each of the following three (3) forms as well as one (1) condition specific form.
Patient Intake Form: please completely fill out this form including your demographic information. Please be sure to fill out the highlighted sections. Please note, the responsible party is the person who is responsible for payment (for a minor child this would be the parent who has the insurance policy in their name).
Health History: This form will help us capture your pertinent medical history. Please fill out as thoroughly as possible. The first section is for any RECENT (the past 7-10 days) medical conditions where as the following section is for any medical condition that you have EVER experienced. Page two captures more information about pain and symptoms. Please be sure to sign and date the bottom of page two. If the patient is a minor, a parent signature is required on this page.
Missed Appointment Policy: Please sign this form indicating that you have read and understood the missed appointment policy, the collections policy, as well as the consent for treatment. If the patient is a minor, a parent signature is required.
Additonal Forms
Orthopedic Outcome Measures
In addition to the packet above, please pick ONE form below. Pick the form that best describes the body part that you are seeking treatment for (neck, arm, back, pelvis, or leg). Filling out this form will help us identify any specific areas where we can focus our interventions to help you the most, help us set goals with you, and act as a measure of progress over the course of your treatment with us.
If you have any questions, you may wait until your first visit and fill out the form upon arrival at our clinic, or you may call us to verify the correct form. 406-502-1782
Neck Pain
For neck pain, whiplash, or other cervical spine conditions, please click below. Please answer all questions including the highlighted question regarding pain with activity.
Arm, Shoulder or Hand
Ifyou are seeing us due to arm, shoulder or hand pain, please fill out this form completely, including the highlighted question regarding pain level with activity.
Back Pain
If you are seeking treatment due to back pain, please fill out this form, including the highlighted section about pain with activity.
Pelvic Floor Dysfunction
If you are being evaluated for urinary incontinence or pelvic floor dysfunction, please fill out this form including the highlighted questions.
Lower Extremity
If you are coming in due to hip, knee, ankle, or foot pain, please fill out this form including the highlighted question about pain with activity.
Concussion Specific Forms:
If we are seeing you for a concussion or a mild traumatic brain injury (mTBI), please fill out one of the following forms in addition to the forms above. Please note, the concussion specific forms are age dependent and should only be filled out if we are seeing you for a concussion.
SCAT5: age 13 and older (on the day of the evaluation). Please fill out the highlighted sections only. Page 1 (name, date of birth, and address) and Page 3 ( Step 1 and Step 2). Filling out this form thoroughly will aid in our ability to completely evaluate your head injury
ChildSCAT5: age 5-12 (on the day of the evaluation). Please fill out the highlighted sections only. Page 1 (name, date of birth, and address), page 2 Office or Off-Field Assessment (lower right hand corner), and page 3 (Symptom Evaluation). Please note that the symptom evaluation for the Child SCAT5 has BOTH a child AND a parent section. Please fill out both sections completely. This will greatly aid in our ability to evaluate your child.
