nmalik@genesisrehabservices.net9430 Wicker Ave, St. John IN 46373 or visit us at 1534 119th Street, Whiting, IN 46394
 
 
 
 
 
 
 
 

Patient Forms in St. John & Whiting, IN


 
At the time of the initial phone call the front office desk should have instructed you on the required functional outcome measurement scales that maybe applicable to your condition. Please read the tests and measures and answer all question to the best of your ability. If you have any questions, then the therapist can help you answers the questions at the time of the initial evaluation.
For your convenience we have provided to you the forms and the paper work that maybe required for your initial evaluation. Apart from the patient intake forms that are separated out with location we have also provided a link for you to print out your customized self-reported functional outcome measurement scales. These scales are required by Medicare and most of the other insurance companies. For example, the Pain and disability index is your report on how pain is effecting your function in daily life. We suggest that you fill out atleast 2 functional outcome measurement scales.
Suggested scales according to the effected joint. Please click on the link/buttons of the corresponding tests to review/print.

1. For ALL patients with pain (except shoulder pain): Pain and Disability Index.

2. For Shoulder/Elbow/Hand: Croft Disability Questionnaire, DASH/Quick Dash, PENN Shoulder Disability Index, and Pain and Disability Index

3. For Neck/Back pain: Spine and Neck Disability Index, Oswerty Scale, Quebec, and Pain and Disability Index.

4. For Hip/Knee/Ankle/Foot Pain: Lower Extremity Functional Scale and Pain and Disability Index.
 
 
 

Please fill out all forms completely with the list of medications and the 6th page for consent to treat. Please sign and initial where indicated.

 
SHOULDER/ARM/HAND
NECK/BACK
 
 
 
 
 
 
HIP/KNEE/ANKLE
 
FOR KNEES ONLY
 
FOR BALANCE