The following questionnaires will give your therapist a better understanding of your present physical condition and functional status. Your insurer will request to see your responses to these questionnaires along with our written daily notes periodically and will use your response to make authorizations for continued physical therapy care based upon this information.
Please note that each question has a number scale associated with it. If your answer should vary between numbers on any indiviual question please indicate how you are at your "worst" rather than your best.
Some patients may need to fill out more than one questionnaire depending upon their specific condition(s). For example, if you are experiencing problems with your lower back AND your leg it would be wise to fill out the LOWER BACK and LEFS questionnaires.
We understand that filling out these forms becomes tedious but they are necessary to progress your care. The more infomation we have, the better we can act on your behalf. Thank you in advance for your cooperation.
Steven L. Braverman, PT PC / RESTORE Physical Therapy 450 Seventh Avenue (corner 34th Street) Suite 302 New York, NY 10123 P: 212.594.6054 F: 212.594.5915 Contact Us
