Patient Information Forms

Please complete the following forms: Choose the appropriate insurance form based on the type of insurance we will be billing, medical history form, and choose the appropriate Functional Questionairre based on the area we will be treating (Fitness Training clients will not need to complete the Functional Questionairre). There is also a copy of our HIPPA policy should you choose to view it. Please contact us if you are confused about which forms you should complete.

General and Insurance Information Forms

Private Health Insurance

Medicare

Motor Vehicle Accident or Workers Comp

Cash Pay Physical Therapy

Fitness Training

Medical History Form 

TAOS Functional Questionairre

Shoulder, Elbow, Arm

Hip, Knee, Ankle, Foot, Leg

Lower Back

Neck, Upper Back

Hand

TMJ

Stroke, MS, Neurological

Multiple Ares (please complete the appropriate sections)

HIPPA Policy


Some health conditions treated at
Goodell Physical Therapy & Fitness Training:

Diabetes       Fibromyalgia       Weight Loss       Exercise       Arthritis       Back Pain       Carpal Tunnel Syndrome       Bursitis       Headaches       Womens Health       Sports Injuries       Joint Pain       Frozen Shoulder       Spondylolisthesis       Kegel Exercises       Heel Spurs       Trauma       Knee Injuries       Degenerative Disc Disease       Chronic Pain       Lordosis       Kyphosis       Muscle Spasms       Fitness Training       Shoulder Injuries       Nerve Pain       Cardiac Rehab       Spondylitis       Foot Injuries/ Foot Pain       Weakness       Hand Injuries       Dupuytren’s Contracture       Shoulder Impingement       Numbness       Elbow Injuries       Neuromuscular Re-education       Ankylosing Spondylitis       Muscle Injuries       Sports Training       Car Accident Injuries       Disc Bulge       Total Joint Replacement       Myofascial pain syndrome       Fasciitis       Balance Training       Fibromyositis       Work Injuries       Whiplash Injuries       Spine Fusion       Ligament Injuries       Complex Regional Pain Syndrome       Back Pain with Pregnancy       Connective Tissue Pain Disorder       Inflexibility       Joint Dislocations       Low Back Pain       Neck Pain       Neural Fibrosis       Spine Stability       Uneven Leg Length       Patella Femoral Dysfunction       Pelvic Pain       Peripheral Nerve Injury       Personal Training       Plantar Fascitis       Pregancy Pain and Fitness       Post Partum Pain and fitness       Sciatica       Orthotics