Client Intake Form
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Date of birth
-
Month
-
Day
Year
Date
Age
Gender
Male
Female
Other
Occupation
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How did you find out about Second Wind Health and Wellness?
Internet search
Doctor referral
Family or friend
Why are you interested in Myofascial Release?
When did your symptoms start?
Less than one month
One to 6 months
6 to 12 months
One plus years
Have you had surgery or any other therapies for this problem?
Yes
No
Are you pregnant?
Yes
No
What tasks are you having difficulty performing?
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Describe the pain
Burning
Sharp
Dull/achy
Throbbing
Shooting
Other
Rate your pain on a scale of 1 to 10
No Pain
1
2
3
4
5
6
7
8
9
Worst Pain
10
1 is No Pain, 10 is Worst Pain
What other issues are you having?
Please list any surgeries, accidents or other conditions and their dates
Where is the pain or tightness located?
What are your goals for being treated?
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 you may be engaging in?
Yes
No
Do you agree not to wear lotions and perfumes of any kind to a myofascial release appointment?
Yes
No
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