Client Evaluation

Full Name

Date (YYYY/MM/DD)

Email

Street

City

State

Zip Code

Phone #

Date of Birth (YYYY/MM/DD)

Age

Gender

Occupation

Hours Worked Per Week

How did you find out about Ascend Therapeutic Services? How did you find out about Ascend Therapeutic Services? Google Search Doctor Referral Friend or Family Member Facebook Instagram Walk-In

Why are you interested in Myofascial Release? Why are you interested in Myofascial Release? Pain Problems Mobility Other

When did your symptoms start/ how did you injure yourself? When did your symptoms start/ how did you injure yourself? Less than One Month 1-6 Months 6-12 Months 1+ Year

Did you have surgery or try any other therapies? Did you have surgery or try any other therapies? Yes No

Are you pregnant? Are you pregnant? Yes No

Do you have any hernias? Do you have any hernias? Yes No

What tasks are you having difficulty performing:

Describe the Pain: Describe the Pain: Burning Sharp Dull/Achy Throbbing Shooting Other

Where is the pain or tightness located and how bad does it hurt (on a scale of 0-10)?

What other issues are you having?

Please list any surgeries, traumas, accidents, or other conditions with their dates. (Sprained ankle, broken arm, car accident, etc.)

What are your goals for getting treated? Be specific on how you want to feel and what you want to do or what you want to be able to do again.

Do you agree to and understand that John F. Barnes’ Myofascial Release Approach® treatment is not a substitute for medical treatment and is an adjunct to any other medical procedures I may be engaging in? I fully disclose any and all health conditions in this form. Do you agree to and understand that John F. Barnes’ Myofascial Release Approach® treatment is not a substitute for medical treatment and is an adjunct to any other medical procedures I may be engaging in? I fully disclose any and all health conditions in this form. Yes No

Do you agree to not wear lotions and perfumes of any kind to a Myofascial Release appointment as to prevent allergic reactions in other patients? This will also allow for the therapists to provide maximum benefits from Myofascial Release treatments. Do you agree to not wear lotions and perfumes of any kind to a Myofascial Release appointment as to prevent allergic reactions in other patients? This will also allow for the therapists to provide maximum benefits from Myofascial Release treatments. Yes No