1-855-5DRAYER

New Patient Forms

Thank you for choosing Drayer Physical Therapy Institute® to provide you with rehabilitation services. We want to ensure that your first visit is as smooth as possible and that all of your questions are answered. To help us better serve you, please bring the following to your appointment:

  •   Photo ID
  •   Current insurance card(s) (or information related to your workers’ compensation or auto injury)
  •   Referral from your physician
  •   Any questions you might have for your therapist

You may also wish to print and complete the following paperwork prior to your visit to decrease your initial visit time.

History Forms

Subjective History – General
Subjective History – Pediatric
Subjective History – Pelvic Girdle
Subjective History – Speech Adult
Subjective History – Speech, Child
Subjective History – Vestibular

FOTO History Forms

FOTO- Subjective History- General
FOTO- Subjective History- Pelvic Girdle
FOTO- Subjective History- Vestibular

Functional Outcome Tools

Arm, Shoulder, Hand – DASH
Arm, Shoulder, Hand – QuickDASH WorkSport
Arm, Shoulder, Hand – QuickDASH
Balance, Gait, Falls – ABC Scale
Barthel Index
Colorectal Distress Inventory
Fear Avoidance Questionnaire, Patients with Back Pain – FABQ
Foot and Ankle – FAAM Sport
Foot and Ankle – FAAM
Hand – HAT
Henry Ford Hospital Headache Disability Index
Hip Outcome Score, Daily Living – HOS ADL
Hip Outcome Score, Sports – HOS SOS
Incontinence Symptom Questionnaire
Knee – KOS ADL
Knee – KOS Sport
Low Back Pain – Modified Oswestry
Lower Extremity – LEFS
Neck Pain Disability Index
Pelvic Floor Impact
Prolapse Questionnaire
Prolapse Questionnaire
TMD Disability Index
Urinary Distress Index
Vestibular – DHI
Walking Scale – MSWS-12
Workers Comp Functional Baseline Questionnaire