Please print all forms and fill out prior to first appointment.

Intake Form

Health History Questionnaire (Page 1)

Health History Questionnaire (Page 2)

Notice of Privacy

Notice of Privacy – Signature needed

Please select the corresponding functional survey for the area of injury you are coming in to be seen for

Low Back Survey

Cervical Disability Survey

Shoulder and Hand Survey

Upper Extremity Survey

Lower Extremity Survey

TMJ Survey

Please fill out our patient satisfaction survey, to let us know how we can improve, and how your overall experience was here at P.O.S.T.-Wellness by Design!

Patient Satisfaction Survey