Printable Patient Forms

On your first visit please bring the following:
Your insurance card, physical therapy referral from your physician, a photo ID and the appropriate forms below. If you have your recent operative reports or MRI/X- Ray results, you may bring us a copy.

Forms to print out and bring with you

All patients:

Missed Appointment Policy

PPO, POS, HMO, Worker's Compensation patients:

Patient Information Form
Past Medical History Form
Consent Form
Mood & Feelings Questionnaire

Medicare patients:

Patient Information Form
Past Medical History Form
Medicare Consent Form
Medicare Cap Information Form
Geriatric Depression Scale

Self-Reported Outcome Measures:
Please select the outcome measure listed below that corresponds with the primary treatment diagnosis that you will be treated for at Success Physical Therapy

Neck pain, Headaches: Neck Disability Index
Low back pain: Oswestry Disability Index
Hip, knee, ankle, foot pain: Lower Extremity Functional Index
Shoulder, elbow, wrist pain: Quick DASH
Dizziness: Dizziness Handicap Index
Gait disturbance/imbalance: Falls Efficacy Scale

Please read the Notice of Privacy Practices and print it out if you would like to retain a copy.

If you have any questions please call us at (310) 325-0800, or email us at SuccessPT@att.net.