Hetrick Center Patient Forms
Downloadable Forms
History Form – If you are a new patient or have not been seen in 1 year
Patient Status Update – If it has been more than six months since your last visit but less then a year
Personal Injury History – If you have been in a car accident, slip and fall, etc.
Work Compensation History – If you have had a work injury
Back Index – If you have back problems
Neck Index – If you have neck problems
Headache Disability Index – If you have headaches
Lower Extremity Functional Scale – If you have hip, knee, leg or foot problems
Upper Extremity Functional Scale – If you have shoulder, arm, elbow, wrist, or hand problems
FABQ – If you are out of work due to an injury
Pediatric History – Children under three
Medication/Supplement List – Any changes to your medication, please reprint and submit to us.