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43 South Main Street

Montgomery, PA  17752

(570) 547-0480

fax (570) 547-0498

info@valleyrehabilitation.com

NEW PATIENT FORMS


We ask that all new clients complete intake paperwork prior to arriving for their first appointment.  We ask that you thoroughly complete the forms pertaining to medical history and the history of your present condition, as these will greatly assist our therapists in streamlining questions and examination techniques and  maximize treatment time.  Intake forms are available below, and are specific to client type; please be sure to select the correct form.  If you have any questions when completing them, please feel free to call!


Our paperwork includes an acknowledgement that you have been provided with a copy of our privacy policy.  The privacy policy is not included in any of the intake forms available below for download, however you can view a copy of it here.  If you would like a copy of our full, unabridged privacy policy, please speak with Melissa Jameson or Susan Andrews.  




GENERAL / ORTHOPEDIC / SPORT INJURIES

Please complete these forms if you will be treated for a diagnosis pertaining to sports injuries or other problems with your arms (or included joints), legs (or included joints), back, neck, balance or walking difficulty, etc.  Please do not complete these forms if we will be treating you for a women's pelvic health condition or if the new client is  a child with a chronic or developmental condition.

 

PLEASE CLICK HERE TO DOWNLOAD GENERAL INTAKE FORMS





pediatric clients

Please complete these forms if we will be treating your child for a developmental or other persistent condition such as a genetic or chormosomal abnormality, Down Syndrome, Cerebral Palsy, Spina Bifida, Autism Spectrum Disorder, etc.  Please complete a general intake packet for children who will be receiving P.T. for an isolated injury or condition. 

 

PLEASE CLICK HERE TO DOWNLOAD STANDARD PEDIATRIC INTAKE FORMS





Pediatric incontinence clients

Please complete these forms if we will be treating your child for incontinence or related condition.

 

PLEASE CLICK HERE TO DOWNLOAD PEDIATRIC INCONTINENCE INTAKE FORMS


PLEASE CLICK HERE TO DOWNLOAD PEDIATRIC BLADDER & BOWEL DIARY(Please print 4 copies of page 1)

PLEASE CLICK HERE TO DOWNLOAD THE BRISTOL STOOL SCALE





WOMEN'S PELVIC HEALTH CLIENTS

Please complete these forms if we will be treating you for a condition such as pelvic pain, constipation, urinary incontinence, fecal incontinence, pelvic organ prolapse or pregnancy-related pain or problems. 


If you have been asked by our staff to complete a bowel or bladder diary, please be sure to download those forms separately and print 4 of each.  Please note that bowel and bladder diaries generally take 4 days to complete.  If completing a bowel diary, please reference the Bristol Stool Scale, if necessary.  It is listed below. 

PLEASE CLICK HERE TO DOWNLOAD WOMEN'S HEALTH INTAKE FORMS


PLEASE CLICK HERE TO DOWNLOAD BOWEL DIARY  (Please print 4 copies of page 1)

PLEASE CLICK HERE TO DOWNLOAD THE BRISTOL STOOL SCALE


PLEASE CLICK HERE TO DOWNLOAD BLADDER DIARY  (Please print 4 copies of page 1)

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