The Hands of Experience® in Advanced Health Care

First Appointment Paperwork

Thank you for choosing St. Mary’s Outpatient Rehabilitation Services and Physical Therapy. At your first appointment, you will be required to fill out several forms to help us better understand your medical history and your symptoms.

The Current and Past Medical Questionnaire must be completed by all patients. Please also complete the form that corresponds with where you are experiencing pain, stiffness or other issue. If you are a Medicare patient, please fill out the Medicare Benefits Questionnaire as well.

Current and Past Medical Questionnaire

Upper Extremity (Shoulder, Elbow or Hand) Pain or Stiffness Questionnaire

Neck Pain Questionnaire

Lower Extremity Pain/Balance/Walking Questionnaire

Back Pain Questionnaire

Medicare Benefits Questionnaire