Chugach Physical Therapy
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        • Laura Croix
        • Rainy Diehl
        • Michelle Drake
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        • Karen Hansen
        • Dorothy Martin-Calkins
        • Linda Sheppard
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        • Lezlie Robinson
        • Jacquline Hartman
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        • Laura Croix
        • Linda Sheppard
        • Joan Stassel
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        • Sammy Dee
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Evaluation Forms

Please print and complete all 4 forms and bring to the evaluation.

Demographics

Demographics.pdf
File Size: 120 kb
File Type: pdf
Download File

Cancellation/No Show Policy

Cancellation/No Show Policy.pdf
File Size: 98 kb
File Type: pdf
Download File

Treatment Authorization

Treatment Authorization.pdf
File Size: 87 kb
File Type: pdf
Download File

Health Info

Health Info.pdf
File Size: 119 kb
File Type: pdf
Download File


The following forms are specific to your diagnosis or reason for coming to physical therapy. You only need to complete the forms that apply to your diagnosis. For example, if you are coming in due to a knee replacement, you only need to fill out the KOOS, JR form. These diagnostic specific forms are in addition the 4 admission forms above required of all patients. If you have any questions about which forms you need to fill out, please don't hesitate to call us at (907) 743-3333. You are also always more than welcome to come to your appointment 20-30 minutes before your evaluation and fill the paperwork out in our office.
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Upper Extremity Functional Scale (UEFS)

Upper Extremity Functional Scale.pdf
File Size: 149 kb
File Type: pdf
Download File

Neck Disability Index (NDI)

Neck Disability Index.pdf
File Size: 105 kb
File Type: pdf
Download File

Oswestry Low Back Assessment (ODI)

Oswestry Low Back Assessment.pdf
File Size: 105 kb
File Type: pdf
Download File

Lower Extremity Functional Scale (LEFS)

Lower Extremity Functional Scale.pdf
File Size: 150 kb
File Type: pdf
Download File

HOOS, JR

HOOS, JR.pdf
File Size: 189 kb
File Type: pdf
Download File

KOOS, JR

KOOS, JR
File Size: 218 kb
File Type: pdf
Download File

Dizziness Handicap Inventory (DHI)

Dizziness Handicap Inventory.pdf
File Size: 167 kb
File Type: pdf
Download File

  • Home
  • About Us
    • Services
    • Contact Us
  • Our Team
    • Midtown Clinic >
      • Therapists >
        • Laura Croix
        • Rainy Diehl
        • Michelle Drake
        • Boyd Esplin
        • Karen Hansen
        • Dorothy Martin-Calkins
        • Linda Sheppard
      • Staff >
        • Lezlie Robinson
        • Jacquline Hartman
        • Jeri Henry
        • Savannah Green
        • Austin Anderson
        • Elizabeth Faaliga
    • South Anchorage Clinic >
      • Therapists >
        • Laura Croix
        • Linda Sheppard
        • Joan Stassel
        • Stacey Szymanski
        • James Werner Jr.
      • Staff >
        • Sammy Dee
  • Evaluation Forms
  • FAQ
    • Preferred Providers
    • Insurance & Billing
    • Evaluation Information >
      • Evaluation Forms
    • Products
  • Fitness Center
  • Blog