Eastern Shore Physical Therapy

Patient Forms

In an effort to provide additional service options to our clients, we have made all patient forms available to you for download.

Please review the menu below and download the appropriate forms for your visit. Please note that all new patients will need to download the New Patient Forms and the Privacy Notice. Other available forms pertain only to specific injuries / problems and you only need to download those that apply to you.

Once you have downloaded the forms you need, you may complete the form on your computer and print it out to bring in or you can simply print the blank form, then fill out by hand prior to your visit.

Please be sure to bring a printed, completed copy of each applicable form along with you on the date of your visit to our office.

These forms are for use with Adobe Acrobat Reader a FREE software available for download by clicking here.

New Patient Forms

Notice of Privacy Practices

Patient History-Intake Form

Patient Information Form

Patient Self-Assessment Form

If Being Seen for Arm, Hand, Shoulder Dysfunction

Disabilities of Arm, Shoulder and Hand Form

If Being Seen for Back Pain

Oswestry Low Back Pain Disability Index

If Being Seen for Neck Pain

Neck Disability Index

If Being Seen for Knee Dysfunction

Knee Outcome Survey

If Being Seen for Foot/Ankle Dysfunction

Foot and Ankle Ability Measure

If Being Seen for Hip Dysfunction

Hip Outcome Score

If Being Seen for Balance Dysfunction

Dizziness Handicap Inventory