Patient Forms
The links below will provide you with our patient forms. Click on the name of the form you were instructed to complete when you made your appointment. You have the option with
only the Patient Agreement form, Patient Questionnaire, and Medical History forms to complete online and email it to
zoe@lakecountrypt.com. If you prefer to print these out, then please do so. Complete them before you come in for your first visit.
In addition, feel free to print out and complete any other forms you were advised before your first appointment. If you do not have a printer be sure to arrive early enough for your first appointment to complete them.
All patients please complete:
For those diagnosed with one or more men’s and women’s health conditions, please also complete:
For those with urinary or fecal incontinence, please also complete the bladder diary form for the 3 days prior to your appointment.
For those with upper, mid and lower back problems, please also complete the Back Index.
For those with any neck problems, please also complete the Neck Index.
For those with elbow, shoulder, wrist or hand concerns, please also complete the DASH form.
For those with hip, knee, leg, ankle, and foot concerns please also complete the LEFS form.
For those experiencing difficulties due to dizziness please also complete the Dizziness Handicap Inventory.
For those experiencing pain or compromised movement in the jaw joint or surrounding muscles please also complete the TMD Disability Index form.
For all others, please complete:
