Patient Forms

TMJ / Jaw Pain Patients

(TMJ, Jaw Pain and Headaches)

Please be sure to complete all 8 forms

• REACH Patient Health History Form
• TMD Disability Questionnaire
• Neck Disability Index
• Financial Policy
• Signature of Receipt of Financial Policy
• Atlas Privacy Practices
• (For Telehealth Patients Only) Acknowledgement of Receipt Of Privacy Practices
• Signature for Privacy Practice Acknowledgement

Dizziness Patients

(Vertigo, Dizziness, Balance Related to Dizziness, Concussions)

Please be sure to complete all 7 forms

• REACH Patient Health History Form
• Dizziness
• Financial Policy
• Signature of Receipt of Financial Policy
• Atlas Privacy Practices
• (For Telehealth Patients Only) Acknowledgement of Receipt Of Privacy Practices
• Signature for Privacy Practice Acknowledgement

Lower Extremity Patients

(Hip, Knee, Ankle, Foot, Walking, Balance Related to Walking or Weakness)

Please be sure to complete all 7 forms

• REACH Patient Health History Form
• Lower Extremity Functional Scale
• Financial Policy
• Signature of Receipt of Financial Policy
• Atlas Privacy Practices
• (For Telehealth Patients Only) Acknowledgement of Receipt Of Privacy Practices
• Signature for Privacy Practice Acknowledgement

Low Back and Sciatica Patients

(Low Back Pain, Sciatica, Lower Thoracic Pain)

Please be sure to complete all 7 forms

• REACH Patient Health History Form
• Modified Oswestry Disability Scale
• Financial Policy
• Signature of Receipt of Financial Policy
• Atlas Privacy Practices
• (For Telehealth Patients Only) Acknowledgement of Receipt Of Privacy Practices
• Signature for Privacy Practice Acknowledgement

Neck Disability Patients

(Neck, Upper Thoracic, and Headaches)

Please be sure to complete all 7 forms

• REACH Patient Health History Form
• Neck Disability Index
• Financial Policy
• Signature of Receipt of Financial Policy
• Atlas Privacy Practices
• (For Telehealth Patients Only) Acknowledgement of Receipt Of Privacy Practices
• Signature for Privacy Practice Acknowledgement

Upper Extremity Patients

(Wrist, Hand, Forearm, Elbow, Shoulder, Arm)

Please be sure to complete all 7 forms

• REACH Patient Health History Form
• Upper Extremity Quick Dash
• Financial Policy
• Signature of Receipt of Financial Policy
• Atlas Privacy Practices
• (For Telehealth Patients Only) Acknowledgement of Receipt Of Privacy Practices
• Signature for Privacy Practice Acknowledgement

Women’s Pelvic Health

Please be sure to complete all 9 forms

• Pelvic Floor Distress Inventory Questionnaire
• Patient Medication List
• Patient Health History and Information
• Informed Consent for Evaluation and Treatment
• Financial Policy
• Signature of Receipt of Financial Policy
• Atlas Privacy Practices
• (For Telehealth Patients Only) Acknowledgement of Receipt Of Privacy Practices
• Signature for Privacy Practice Acknowledgement

Men’s Pelvic Health

Please be sure to complete all 9 forms

• Pelvic Floor Distress Inventory Questionnaire
• Patient Medication List
• Patient Health History and Information
• Informed Consent for Evaluation and Treatment
• Financial Policy
• Signature of Receipt of Financial Policy
• Atlas Privacy Practices
• (For Telehealth Patients Only) Acknowledgement of Receipt Of Privacy Practices
• Signature for Privacy Practice Acknowledgement

Additional Forms

• Authorization To Use Or Disclose Medical Information
• Atlas Privacy Practices
• Referral Form
• Signature for Privacy Practice Acknowledgement