Myofascial Release Therapy | Lake Elsinore, CA | Pain Relief

Address: 31577 Canyon Estates Drive, Lake Elsinore, California 92532 United States

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General Intake Form

General Intake Form

Client Contact Information

Client Contact Information

Client Contact Information

First Name

Last Name

Phone Number

Email

Birth date

Street address

City

State

Zip code

Emergency Contact Information

Emergency Contact Information

Contact Name

Phone Number

How did you hear about us?

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Issues to Address

Issues to Address

Describe sensation(s) i.e. tight, sharp pain, sore, bruising, dull ache, etc.

Cause of injury or concern

How long since first noticed

Treatment Goals

Past treatments

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COVID-19 SYMPTOMS

COVID-19 SYMPTOMS

Please check the box below if any of the following are true:

Have had a fever within the last 24 hours
Recently experienced respiratory/flu symptoms, sore throat, or shortness of breath
Contact, within the last 14 days, with anyone diagnosed with COVID or related symptoms

COVID Symptoms Questionnaire

COVID Symptoms Questionnaire

CARDIOVASCULAR

Blood Clotes

High Blood Pressure

Varicose Veins

Congestive Heart Failure

Phlebitis

Heart Attack

Lymphedema

Heart Disease

Myocardial Infarction

Cold Hands

Pacemaker

Cardiovascular Accident

Low Blood Pressure

Cerebral-vascular Accident

Stroke

Cold Feet

Thrombosis/Embolism

RESPIRATORY

Asthma

Bronchitis

Emphysema

Shortness of Breath

Chronic Cough

SKIN

Bruise Easily

Hypersensitive Reaction

Skin Conditions

Skin Irritations

Melanoma

HEAD & NECK

Ear Problems

Headaches

Hearing Loss

Jaw Pain (TMJD)

Migranes

Sinus Problems

Vision Loss

Vision Problems

INFECTIOUS CONDITIONS

Athlete's Foot

Hepatitus

Herpes

Respiratory Conditions

Skin Conditions

HIV

REPRODUCTIVE

Gynecological Issues

Pregnancy

Number of Pregnancies

Number of Live Birth

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Number of Misscarriage

NEUROLOGICAL

Burning

Tingling

Cerebral Palsy

Multiple Sclerosis

Numbness

Stabbing Pain

Parkinsons

Herniated Disc

FAMILY HISTORY

Cardiovascular Conditions

Respiratory Conditions

MISCELLANEOUS

Allergies

Dizziness

Cancer

Mental Illness

Anaphylaxis

Hemophilia

Surgical Pins or Wire

Artificial Joints/Special Equipment

Osteoporosis

Arthritis

Fibromyalgia

Gout

Epilepsy

Osteoarthritis

Crohn's Disease

Stress

Insomnia

Rheumatoid Arthritis

Diabetes

Loss of Sensation

Shingles

Digestive Conditions

Lupus

Other Diagnosed Diseases

Other Medical Conditions

MEDICATIONS

PREVIOUS SURGERIES/MAJOR ACCIDENTS

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Additional questions

Additional Questions

What does this pain keep you from doing?

How does this effect you?

How does it effect the people you love?

What will happen if nothing changes?

How many MFR treatments are you willing to try?

On a scale of 1-10 what is your belief level that you can get better?

How much time and money have you already spent trying to feel better?

What is the cost of not getting relief?

Any Surgery or Major accidents?

Please come to your appointment with no oils or lotions on your body. Either wear or have ready to change into loose shorts and a sports bra.

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Home
MFR
Videos
Blog
About Me
General Intake Form
Contact Us

Contact Information

Phone:

Email:

vwbmfr@gmail.com

Address:

31577 Canyon Estates Drive, Lake Elsinore, California 92532 United States

FSA and HSA certified

HIPAA-compliant

Business Hours

Mon, Wed: Closed
Tue, Thu, Fri: 9:00 am - 5:00 pm
Saturday: 10:00 am - 4:00 pm
Sunday: Closed

Cash Payment Accepted

Check Payment Accepted

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