FORMS
NEW PATIENT REGISTRATION FORMS
OPTION 1: Fill out the TWO forms electronically on your computer, then print and SIGN the forms.
OPTION 2: Print both of the blank forms and then fill out by hand.
- Please complete and sign BOTH of the following forms BEFORE you arrive for your first appointment.
- You may FAX these forms to us at 330-659-4052.
- OR, please bring these completed forms to the first appointment.
- If you have INSURANCE questions, please call us at 330-659-4050.
- You may copy and FAX BOTH SIDES of your INSURANCE CARD; include your DATE OF BIRTH and PHONE NUMBER. We will then verify your insurance benefits for outpatient physical therapy.
- PLEASE DON'T FORGET THE HIPPA FORM!!
FORM 1. NEW PATIENT REGISTRATION FORM
FORM 2. HIPPA-Consent for Use and Disclosure of Protected Health Information
- Please carefully review the forms below.
- You may print them for your records.
Notice of Protected Health Information Practices
If you have questions about any of these forms, please contact us.
FUNCTIONAL QUESTIONNAIRES
- Choose the BEST questionnaire, then fill it out, print it, and bring it in.
- You may FAX it to us at 330-659-4052.
- You should complete this format the BEGINNING, MIDDLE, and END of your treatment at ACTIV so we (and you) can track your progress!
- PLEASE SELECT ONLY ONE ANSWER FOR EACH QUESTION. Then total your score!
Foot & Ankle, Knee, Hip, Leg (LEFS)
Lower Back, Mid-Back (BACK INDEX)
Neck, Upper Back, Shoulder Blade Region (NECK INDEX)
Shoulder, Elbow, Wrist, Hand, Arm (DASH)
Fear-Avoidance Questionnaire (optional, or by therapist request)
PATIENT SATISFACTION QUESTIONNAIRE
- When your treatment is complete, please complete this last form.
- You may FAX it to us at 330-659-4052.