Intake Forms
Instructions
Complete all intake forms and choose the appropriate OMT (Outcomes Measurement Tool) form below to complete.
Once done, save the completed forms to your desktop/laptop and send your file to: company@8020ptandwellness.com
OMT (Outcomes Measurement Tool)
Please choose one of the below forms that best relates to why you are seeking our care.
DASH
Injuries/pain including shoulder, elbow, wrist, hand, and/or fingers.
LEFS
Injuries/pain including hip, knee, ankle, foot, and/or toes.
Oswestry
Injuries/pain of the upper back, mid back, low back, and/or SIJ (Sacroiliac joint).
Neck
Injuries/pain of the neck and/or headaches.
MFES
Frequent falls, balance and/or stability difficulties
Dizziness
Vertigo – A diagnosis of vertigo or “dizziness” is needed
Referring Doctors
Physical Therapy Order
As provided by a physician