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Pacific Clinic ("PC") assessment form is used to determine the necessity of functional exercise and activities for the physical, emotional and mental well-being of clients. COMPLETING THIS FORM DOES NOT AUTOMATICALLY ENROLL YOU IN A WELLNESS PLAN. PLEASE CALL 509-783-5465 TO SCHEDULE AN APPOINTMENT TO GET ENROLLED.


The health and safety of our members, guests and employees is a top priority for the PC.

I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury (or illness) to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at the PC or my participation in PC programming (“Claims”). On behalf of me and my children, I hereby release, covenant not to sue, discharge, and hold harmless the PC, its owners, employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto.

I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the PC, its owners or employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after my participation in any PC usage, lesson, class, or program.

By completing this form I authorize The Pacific Clinic to use and disclose the protected health information described in this assessment to their medical director and necessary team members to aid in my treatment and care at the facility.

This authorization for release of this information covers the period of

all past, present, and future periods.

Help Us Care For You! 

What is Your Sex?
Do you or any of your family members struggle with chronic, or degenerative illness?
Do you suffer from reccurent chronic pain, injuries, or illnesses?
Are you caring for another person with an aging or degenerative disease?
How often do you feel stressed?*
Stress LevelI'm never stressedI'm rarely stressedI'm occasionally stressedI'm regularly stressedI'm constantly stressedStress Level
How often are you physically active?*
Activity LevelI don't exercise at allI excercise inconsistantlyI exercise weeklyI exercise dailyI train for athletic performanceActivity Level
How happy are you with your primary care?*
Primary CareI'm not satisfied at allI'm often unhappyThey are okThey do a good jobI'm completely happyPrimary Care
How is your sleep pattern?*
Activity LevelI can't sleep for several daysI don't fall asleep easilyI get enough sleepI often feel well rested after sleepI have no problems with my sleepActivity Level
How comfortable are you with your workout plan?*
Activity LevelI dont have oneI need some workout routine helpI dont plan my workoutsI'm comfortable with itI already have an expert planActivity Level
How are your continued effects of Covid?*
Activity LevelNo continuing effects for covid Not sure if Covid related but I feel unwellI have some continuing effects from having covidPost Covid symptoms effect me daily I could use some support with my post-covid symptoms Activity Level

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