• HOME
  • CONTACT
  • ABOUT
  • MYOFASCIAL RELEASE
  • CLIENT INFO
  • CLIENT FORMS
  • RESOURCES
  • Inspiration

Client Forms



Click on a link below, and the appropriate form will come up in a new window in your browser. Print it, fill it out, and bring it along to your appointment or, download and rename it to include your name, fill it out with a pdf program and email it to:


Jean@Hands-On-Therapy.net



initial evaluation



Client intake form


HIPAA Disclosure form


Pelvic Floor Treatment Consent



back & neck



Neck pain/stiffness (NDIQ)


Low back pain/stiffness (Oswestry) - initial


Low back pain/stiffness (Oswestry) - followup



upper body



Shoulder pain/stiffness (SPADI)


Arm and hand problems (DASH)


Upper body problems (UEFI)



lower body



Lower body problems (LEFS)


Hip pain/stiffness (HOOS) - initial


Hip pain/stiffness (HOOS) - followup


Knee pain/stiffness (KOOS) - initial


Knee pain/stiffness (KOOS) - followup


Foot pain (FFI)



fibromyalgia & pelvic floor



Fibromyalgia (FIQR)


Fibro daily symptoms (VASFIQ)


Pelvic Floor issues (PFDI)


Incontinence issues (CGS)



balance & dizziness



Dizziness issues (DHI) - initial


Dizziness issues (DHI) - followup


Balance issues (MFES) - initial


Balance issues (MFES) - followup



Special promotion!





GET 25% OFF Your first purchase!

Send us your name and email address and we'll send you a coupon!






submit