Pre Visit Assessment

Client screening • Movement & recovery consultation • Personalized service discussion

Client Information

Full name

Assessment date

Phone or email (optional)

Quick Pain Questions

2. Pain Location & Type — Where do you feel discomfort? (select all)Which best describes the discomfort?

Pain right now (0 = none, 10 = worst imaginable)

4 / 10

4. How long?

5. What makes it worse?6. What is your main goal?7. Any known diagnosis, recent injury, surgery, or restrictions?Additional comments or concerns (optional)

Service Interest

Which OLY Recovery service are you interested in? Select one. Your practitioner will review the best option during your visit.

Single / Targeted Therapy — 20 minutes · $75 Kinesio Therapy — 30 minutes · $110 Olympic Therapy (Olympic Recovery) — 40 minutes · $150

Save downloads a completed, reopenable HTML copy; Print lets you print or save as PDF. This questionnaire supports pre-visit planning only. It does not diagnose arthritis, injury, or the cause of pain. A practitioner must review the answers and confirm whether services are appropriate.

Pre-Visit Assessment Summary

Recommendations are preliminary and depend on professional screening, consent, and applicable scope of practice.