Patient Forms

/Patient Forms
Patient Forms 2018-09-20T19:00:27+00:00

Prepare for Your First Visit to Millennium Rehabilitation

Make your first visit at Millennium Rehabilitation run as smoothly as possible; please bring the following documents and forms regarding your background and medical history:

  • Insurance ID Card
  • Drivers license or State Photo ID
  • PT order (if provided by your physician)
  • List of Medications (if applicable)

REQUIRED FORMS – click to download and print the following forms for your visit:

Demographic Form
Health Questionnaire
Patient Acknowledgement

ADDITIONAL OPTIONAL FORMS – In order to get a good understanding of your pain and/or symptoms, please fill out the form/forms below that coincide with the area of the body your pain/symptoms are involved with:

Neck Index
Back Index
Lower Extremity Function Scale
DASH (Arm, Shoulder, Hand)