Waynesboro Physical Therapy
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Intake Forms

We value your time and your privacy. Therefore, we have provided our New Patient forms for you to download, print, and fill out at home. Please fill out ALL of the following INTAKE FORMS and bring them into our clinic during your next visit.
Medical History Questionnaire
File Size: 60 kb
File Type: pdf
Download File

Patient Information
File Size: 525 kb
File Type: pdf
Download File

Privacy Practices Brochure
File Size: 449 kb
File Type: pdf
Download File

Therapy Participation Form
File Size: 659 kb
File Type: pdf
Download File

Visual Pain Scale Form
File Size: 144 kb
File Type: pdf
Download File

Medicare Medication List Form
File Size: 435 kb
File Type: pdf
Download File

Disability IndICes

For your convenience, we have provided injury specific forms for you to download, print, and fill out at home. Please chose only ONE of the following forms that best matches your diagnosis and bring it along with your intake forms, during your next visit.
Ankle Foot Injury
File Size: 48 kb
File Type: pdf
Download File

Hand Injury
File Size: 74 kb
File Type: pdf
Download File

Knee Injury
File Size: 62 kb
File Type: pdf
Download File

Hip Injury
File Size: 81 kb
File Type: pdf
Download File

Knee Injury Surgery
File Size: 62 kb
File Type: pdf
Download File

Lower Back Injury
File Size: 76 kb
File Type: pdf
Download File

Neck Injury
File Size: 91 kb
File Type: pdf
Download File

Shoulder Injury
File Size: 59 kb
File Type: pdf
Download File

Upper Extremity Injury
File Size: 69 kb
File Type: pdf
Download File

Picture

Location

118 Walnut St., Unit 114, Waynesboro, PA 17268

Telephone

(717) 655 - 5681

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© 2022 Waynesboro Physical Therapy & Sports Medicine
  • About
  • Services
  • Forms
  • Staff
  • FAQ'S
  • Locations
  • Contact