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Trinity Wellness Center

Forms

The following forms must be completed before initial evaluation at Trinity Wellness. You are always welcome to complete them at our clinic, or for your convenience they can be downloaded through the below links and brought with you to your initial visit or sent to us via email. In addition to the basic intake information, regulations require that we obtain ongoing measures of pain and functional limitations.

 

All patients must fill out the Patient Intake Packet, Pain Scale and at least one Functional Scale. Please select the functional scale that most closely represents your area of pain. If you have multiple injury sites, you may fill out more than one or select the scale that most closely corresponds with your most limiting areas. It is important that your medication list in the Intake Packet includes the name, dosage, frequency, and how you take the medicine. Feel free to bring us a separate list if you have one already prepared. Please fill out to the best of your ability and we will assist you with any questions at the clinic.

 

 

 

Patient Intake Packet**

Patient Pain Scale**

Back Function Scale*

Neck Functional Scale*

Leg Functional Scale*

Arm Functional Scale*

Financial Policy (for reference only)

Privacy Practices (for reference only)

 

 

** All patients must complete.

* Choose Scale that most closely represents your area of injury/limitation.