Client Evaluation

& Medical History Form

Please Fill Out the Following Form

Include as much detail as possible.

How did you find out about Ascend Therapeutic Services?

Why are you interested in Myofascial Release?

When did your symptoms start/ how did you injure yourself?

Did you have surgery or try any other therapies?

Are you pregnant?

Do you have any hernias?

Describe the Pain:

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 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.

12 + 6 =