Printable Forms

The forms available through this page can be downloaded, filled-out (manually or type in the actual pdf file), and printed, giving you the ability to fill out the necessary paperwork before you visit our office. You may also choose to email the form(s) to: info@madetomovept.com This will speed up your visit and help us treat you quicker. Our forms are available in the Adobe PDF format. PLEASE DOWNLOAD THE FORM(S) FIRST, prior to filling out the form, otherwise your typed information will not be saved!!

ALL NEW PATIENTS: PLEASE FILL OUT AND PRINT the "NEW PATIENT PACKET". There are EIGHT (8) pages within this downloadable file. ALL must be filled out completely. Please also read the HIPAA compliance policy under "patient privacy" in the PATIENT INFORMATION drop down menu before signing "Acknowledgement of Receipt of Notice of Privacy Practices" (one of the forms within form "NEW PATIENT PACKET").

If your are coming to Made to Move WITHOUT a doctor's referral/prescription (Direct Access), then, in addition to the new patient paperwork, you must also read and sign the DIRECT ACCESS DISCLOSURE form. If you are a returning patient to the clinic, please fill out the RETURNING PATIENT PACKET only.

SPECIALTY FORMS (IN ADDITION TO EITHER INTAKE OR RETURNING PACKET): If the patient is a minor, the authorization to treat a minor, in the NEW PATIENT PACKET, must also be filled out. Patients that are infants or toddlers, please also complete "Infant Child Medical History". Complete the "Back Questionnaire" for patients who are being treated for a back problem and/or sciatica, and "Neck Disability Questionnaire" for those patients who are being treated for a neck problem. Upper Extremity patients complete "Quick DASH Shoulder Questionnaire". Lower Extremity patients complete "Lower Extremity Functional Scale". Pelvic floor and women's health patients, please complete the "Pelvic Floor" medical history form.

PLEASE DOWNLOAD THE FORM(S) FIRST, prior to filling out the form, otherwise your typed information will not be saved!!

Step 1: Fill out either "new patient" or "returning packet":

New Patient Packet

Returning Patient Packet

Step 2: If your are coming to Made to Move WITHOUT a doctor's referral/prescription (Direct Access):

Direct Access Patients (No Doctor Referral)

Step 3: Fill out the appropriate questionnaire below based on your condition:

Pelvic Floor

Infant Child Medical History

Back Patients:  Oswestry Back Questionnaire

Neck Patients:  Neck Disability Questionnaire

Upper Extremity Patients (Shoulder/Elbow/Wrist/Hand):  Quick DASH Shoulder Questionnaire

Lower Extremity Patients (Hip/Knee/Ankle/Foot):  Lower Extremity Functional Scale

After you have completed your treatment at Made to Move Physical Therapy, Inc., please feel free to fill out the DISCHARGE SURVEY. We always appreciate customer feedback and want to know how we are doing to satisfy your needs as a client. Please mail back to:

Made to Move Physical Therapy, Inc.
615 N Nash St., Suite # 306
El Segundo, CA 90245

Patient Discharge Survey