Patient Forms

If you are a new patient of Wayne Physical Therapy & Spine Center, you may be interested in printing out our patient forms to bring with you on your first visit. This will save you the time of having to do it at our office.

We ask that all patients fill out our patient form packet, which contains our Patient Information Form, our Medical History Form and our Authorization For Treatment Form. For patients being treated for neck and/or back pain, please also fill out our Spinal Questionnaire. For patients with upper extremity injuries please also fill out our Disabilities of the Arm, Shoulder and Hand (DASH) form and for those with lower extremity injuries, our Lower Extremity Functional Scale, (LEFS). If you decide to fill out these forms in advance, please let the person who sets up your first appointment know you will be bringing the completed forms with you on your first visit!

• Patient Form Packet
• Spinal Questionnaire
• Disabilities of the Arm, Shoulder and Hand (DASH)
• Lower Extremity Functional Scale (LEFS)
• Satisfaction Survey
• Driving Directions

As patient satisfaction is our priority as you complete physical therapy at our facility we invite you to complete our patient satisfaction survey and mail, Fax or email it to us!

• Patient Satisfaction Survey