Name of Clinic

Month, Year

Med-Fit Assessments

Total: ​#

---

Baseline Assessments
Total: #

Date     Client's Name     Phone #    Tech

Date     Client's Name     Phone #    Tech

​Date     Client's Name     Phone #    Tech

---

Follow-Up Assessments
Total: #

Date     Client's Name     Phone #    Tech

Date     Client's Name     Phone #    Tech

​Date     Client's Name     Phone #    Tech

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Clinic Reports

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Month, Year = June, 2025 (example)

Total # = The total # of Clients that had a Baseline Assessment this Month at this Clinic.

Client's Name = LastName, FirstName

Clients are listed in chronological order by Date of Service
​
Tech = FirstName & LastInitial of the Technician that provided the Service to that Client.

Clinic Reports