B. Specific Data Request/Description: What type of data are you requesting? Please select all relevant options.

Date Range: ☐Last one year ☐ Last two years ☐ All Available data Date Range: Begin: Click here to enter a date.End: Click here to enter a date.

Data Format: ☐.csv	☐ .dta	☐.xlsx

Care Types:	☐ Orthopedic	☐ Speech

☐ Industrial	☐ Wound

☐ Pain Management	☐ Cardiovascular and Pulmonary

☐ Neurological	☐ Pelvic Floor Dysfunction

Body Parts: If you selected Orthopedic, Industrial or Pain Management care type, please specify Body Part(s).

Mark (R – Individual Survey Response, S – Score Only, B – Both Responses and Score)

____ Shoulder

____ Upper Arm

____ Elbow

____ Forearm

____ Wrist

____ Hand

____ Pelvis

____ Hip

____ Upper Leg

____ Knee

____ Lower Leg

____ Ankle

____ Foot

____ Craniofacial

____ Neck

____ Ribs – Trunk

____ Thoracic Spine

____ Lumbar Spine

Impairment Types: If you selected Neurological care type, you must also indicate which Impairment type(s) you would like. For the other care types, it is optional to specify Impairment. (Example: Arthropathies is available for Industrial, Ortho, Pain Management and Wound)

Impairment Category	Orthopedic	Industrial	Pain Management	Neurological	Speech	Wound	Cardiovascular
☐ Arthropathies	O	I	P	W
☐ Brain Injury	N	S	W
☐ Burns	O	I	P	W
☐ Cancer	O	I	P	N	S	W	C
☐ Cerebrovascular Disorders	P	N	S	W	C
☐ Complications + Unspecified Injuries	I	N	S	W
☐ Congenital Anomalies	N	S	W
☐ Contusions	O	I	P	W
☐ Crushing Injuries	O	I	P	W
☐ Degenerative CNS Disorders	N	S	W
☐ Diseases of Arterial System	P	N	S	W	C
☐ Diseases of Veins and Lymphatics	P	N	S	W	C
☐ Dislocations	O	I	P	W
☐ Endocrine, Metabolic and Immunity Disorders	N	S	W
☐ Fractures	O	I	P	W
☐ Inflammatory Diseases of the Nervous System	N	S	W
☐ Injury to Nerves Other than Spinal Cord	O	I	P	W
☐ Lung Disease	C
☐ Multiple Sclerosis	N

Impairment Category	Orthopedic	Industrial	Pain Management	Neurological	Speech	Wound	Cardiovascular
☐ Muscle, Tendon + Soft Tissue Disorders	O	I	P	W
☐ Neurotic, Personality and Other Non-Psychotic	N	S	W
☐ NOC-musculo-skeletal disorder	O	I	P	W
☐ NOC-Neuromuscular disorder	I	P	N	S	W
☐ Non-Traumatic CNS Dysfunction	N	S	W
☐ Osteo, Chondropathies and Acq Mus-skel Deform	O	I	P	W
☐ Other Paralytic Syndromes	I	N	S	W
☐ Paraplegic Syndromes	I	N	S	W
☐ Peripheral Nervous System Disorders/Injuries	O	I	P	N	S	W
☐ Post-surgical procedures: Musculo-skel, Sys	O	I	P	W
☐ Post-surgical procedures: Nervous system	O	I	P	N	S	W
☐ Psychotic Conditions	N	S	W
☐ Quadriplegic Syndromes	I	N	S	W
☐ Rheumatic and Heart Disease	P	N	S	W	C
☐ Spine Pathology	O	I	P	W
☐ Sprains / Strains	O	I	P	W
☐ Vertigo	N	S	W
☐ Wounds and Traumatic Amputation	O	I	P	W

If you selected Pelvic Floor Dysfunction, please specify which Impairment types:

☐ Urinary (FS measures = the Urinary Function CAT and the Pelvic Floor Dysfunction Index)

☐ Bowel (FS measures = the Bowel Function CAT and the Pelvic Floor Dysfunction Index)

☐ Pelvic Pain (FS measure = the Pelvic Floor Dysfunction Index)

☐ Prolapse (FS measure = the Pelvic Floor Dysfunction Index)

Note: Based on your choices for Care Type and Body Part/Impairment, data will be pulled using the Primary Functional Status (FS) Computer Adaptive Testing (CAT) Outcome Measure relevant to your choice. E.g., the Lumbar CAT, the Shoulder CAT, etc. The primary FS CAT measures are mandated for all patient episodes.

In addition to primary FS CAT measures described above, data from secondary measures may be available. Secondary measures are optional for use in the FOTO system; sample sizes may be limited.

Secondary/Optional Measures: Mark (R – Individual Survey Response, S – Score Only, B – Both Responses and Score)

____ Abbreviated ABC Scale

____ ABC Scale

____ Activities of Daily Living

____ Depression Subscale (SCL BPPM)

____ Dizziness Handicap Inventory

____ Employment Information

____ FACIT Fatigue Scale

____ Fear (FABQ-Physical)

____ Fear (FABQ-Work)

____ Global Rating of Change

____ HOOS, JR.

____ KOOS, JR.

____ LE & Mobility

____ Level of Pain in Last 24 Hours

____ Lower Extremity Functional Scale

____ MFIS Measure

____ Modified Oswestry LBP Disability Ques

____ Oswestry Disability Index 2.0

____ NeuroQOL - Ability to Part in SRA

____ NeuroQOL – Communication

____ NeuroQOL - Fatigue

____ NeuroQOL - Lower Extremity

____ NeuroQOL - Pos Affect and Well-Being

____ NeuroQOL - Upper Extremity

____ NeuroQOL UE Fine Motor/ADL Short Form

____ NDI

____ Optional Demographics

____ Pain Catastrophizing Scale

____ Pain Module

____ Patient History

____ Pain Disability Index 7

____ PFDI 20

____ PFIQ 7

____ PISQ 12

____ PQRS Measure 131

____ PQRS Measure 154

____ PROMIS® Global Health version 1.1

____ Patient Specific Functional Scale

____ Referral Intake

____ Referral Status

____ Roland-Morris Low Back Disability

____ Satisfaction

____ Pain Self-Efficacy

____ Somatization Subscale

____ SRS-22

____ STaRT Back Screening Tool

____ Stroke IS

If you selected a Secondary/Optional Measure(s), please specify patient population by describing which of your selected Care Type/Body Part/Impairment types is relevant. For example, Ortho/Lumbar patients who also took the ABC Scale.

Other Variables	:

Other variables are optional for use in the FOTO system except where the item is indicated as mandatory; sample sizes for optional variables may be limited.

* Mandatory other variables

**Risk-adjusted Predicted Data is only available for the primary FS CAT measures.

☐ Org Id *

☐ Org Name *	☐ Blinded	☐ Not blinded

☐ Site Id *

☐ Site Name *	☐ Blinded	☐ Not blinded

☐ City *

☐ State *

☐ Clinician Id *	☐ Blinded	☐ Not blinded

☐ Clinician License

☐ Alternate Clinicians

☐ Patient Id *	☐ Blinded	☐ Not blinded

☐ Setup Date *

☐ Intake Date *

☐ Status Date (Last Status) *

☐ Staff Discharge Date *

☐ Height *

☐ Weight *

☐ Exercise *

☐ Medicine *

☐ Previous Treatment *

☐ Surgery History *

☐ Onset *

☐ Health Problems *

☐ Non-Participation Reason

☐ Incomplete Discharge Reason

☐ Optional Referral Code Physician

☐ Optional Referral Code Insurance

☐ Optional Referral Code Employer

☐ Optional Referral Code Other

☐ Payer Source *

☐ Referral Source

☐ Duration *

☐ Interruption Days

☐ Number of Visits *

☐ Number of PT Visits

☐ Number of OT Visits

☐ Number of ST Visits

☐ Number of RT Visits

☐ Number of RN Visits

☐ Number of Other Visits

☐ Net Revenue

☐ Exercises

☐ Physical Agents

☐ Procedures

☐ Staff Utilization

☐ Compliance - Attendance

☐ Compliance - Home Program

☐ Compliance – Effort

☐ Primary ICD-9

☐ Secondary ICD-9

☐ Primary ICD-10

☐ Secondary ICD-10

☐ Who Discharged

☐ Goals

☐ PQRS Measure 128

☐ PQRS Measure 130

☐ PQRS Measure 155

☐ FOTO Predicted FS Change**

☐ FOTO Predicted Visits**

☐ FOTO Predicted Satisfaction**

☐ FOTO Predicted Duration**

☐ MDC (If available)

☐ MCII (If available)

☐ Proxy and Recorder Info

☐ Utilization Bucket (1-9)

☐ Surgical Codes

☐ Other, Please specify: