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Patient Medical Forms

Our clinic may require that you fill out an intake medical form during your first visit. Although it can be filled out in person, we are publishing this form online for over-achievers. Call us to see if filling out this form now would be beneficial.

Choose either the Printable OR Interactive form version below.  (The Interactive form can be filled out on your computer using Adobe Acrobat, which is a free download.)


Click to Download:
Review of Systems Form (Printable Version)
Review of Systems Form (Interactive Version - Requires Adobe Acrobat)

  • Please download only one version above. 
  • Email it as an attachment to OR bring it to your upcoming visit.

Montgomery Office
8099 Cornell Rd.
Suite 100
Cincinnati, OH 45249
Physical Therapy
Suite 201 • 513-985-2256

Fairfield Office
5900 Boymel Drive
Fairfield, OH 45014
Physical Therapy
MRI – 2960 Mack Road
Suite 106 • 513-942-4444

Fort Wright Office
1955 Dixie Highway
Suite K
Fort Wright, KY 41011

Lebanon Office
100 Arrow Springs Blvd.
Suite #2600
Lebanon, OH 45036

Lebanon Physical Therapy
Rivers Crossing
Shopping Center • 440 Corwin Nixon Boulevard,
S. Lebanon, Ohio 45065

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