Physical Therapy Patient Forms

Please print and complete the necessary forms before arriving at your appointment time, this will allow us to optimize your time at our facility. If you are a new patient that has not been at a Spectrum Medical’s facility or has not been seen within the last year, please print and complete the following forms for registration and also complete one of the questionnaire forms or Pain Sheet for your Initial Evaluation.

• Danville Physical Therapy Referral Form
• Martinsville Physical Therapy Referral Form

Complete any of the following that is associated with your specific injury:

• Lower Extremity Questionnaire
• Back & Spine Questionnaire
• Shoulder, Arm, Elbow, Wrist, and Hand Questionnaire
• Neck Questionnaire
• Functional Capacity Evaluation or Impairment Rating

If none of the previous questionnaire forms relate to your specific injury, please print and complete the Pain Sheet before you arrive at Spectrum Medical Rehabilitation for your Initial Visit.

If you have any questions, feel free to contact our office at 434-793-4711 Option 2 for help.