Forms

Required Forms for New Patients:
Not all forms are required for each person. Please ask when you call to schedule which forms will be needed for your specific case. Please bring your insurance card and these forms filled out to your first appointment.

Restore Physical Therapy Patient Information and Legal Form

These forms contain our legal information that require your signature and should be brought with you to your first visit. You only need to print and sign the first page. Please review the last page regarding our “Notice of Privacy Practices” before signing our “Patient Acknowledgement” form.

General Health Questionnaire

This questionnaire will provide your therapist with your background information as well as your health concerns and goals for recovery. We ask all new patients to please fill out this form prior to your first visit. If you have a medications list, please bring that with as well and we will make a copy for your therapist.

Pelvic Health Questionnaire

This form will provide your therapist with more detailed information regarding your pelvic floor, bladder, and gynecological history. This will also help to make you more aware of some of the habits you may have.

Progress is already achieved on the first step

Forms

Restore Physical Therapy Patient Information and Legal Form

General Health Questionnaire

Pelvic Health Questionnaire

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is already achieved on the first step