Name__________________________________ Referred By____________________________________
Address_________________________________ City___________________________ ZIP____________
Phone (day)______________________________ (evening)__________________________________
Occupation_____________________________________
DOB_______/________/________ Height__________ Weight_________ Age____________
| Do you have or have you ever had any of the following? (Yes or No) | ||||
| Heart condition | Chiropractic care | |||
| Cancer | Thyroid problems | |||
| Arthritis | Diabetes | |||
| Convulsions | Osteoporosis or osteomylitis | |||
| Phlebitis or hemophilia | Orthopedic braces or shoes | |||
| Kidney or urinary problems | High or low blood pressure | |||
| Contact lenses | Dentures or removable bridge | |||
| Allergies | Hernias | |||
| Sinus problems | Pregnancy/miscarriage/abortions | |||
| Whiplash | Surgical pins/plates | |||
| Scoliosis | T.M.J. syndrome | |||
| Chronic or recurrent pain | Cosmetic surgery | |||
| Headaches | Respiratory disorder | |||
| Ulcer or digestive disorder | Degenerative joint disease | |||
Bave you had any broken bones or major sprians?__________ Briefly describe:_________________________
________________________________________________________________________________________
Any major injuries, illnesses or accidents?____________ Briefly describe:_____________________________
_______________________________________________________________________________________
Have you had any surgery?____________ Briefly describe:________________________________________
_______________________________________________________________________________________
What medications have you taken during the last six months?_______________________________________
Are you being treated by a medical or chiropractic doctor? _________________________________________
Are you presently in psychological therapy?____________________________________________________
Have you ever been physically or sexually abused?______________________________________________
What chronic bodily discomforts are you aware of?______________________________________________
Are you pregnant?______________ Do you have an I.U.D.?___________________
Are there any activities from which you are restricted?_____________________________________________
_______________________________________________________________________________________
What kind of exercise do you do regularly? How many hours per week?______________________________
________________________________________________________________________________________
Are you or have you ever been involved in any self-improvement programs (yoga,
est, silva, tai chi, holistic health classes, therapy, counseling, landmark
education, etc.)?
______________________________________________________________________________________
Why do you want to get Rolfed?____________________________________________________________
_____________________________________________________________________________________
Due to the large amoount of time that must be blocked out for each appointment, it is necessary to require 24 hours notice of all cancellations or the full fee will be charged.
I certify that the above stated information is true and accurate to the best of my knowledge, and i agree to keep my appointments in a timely manner.
Signature__________________________________________ Date____________________________________
® The word Rolfing is a Service mark of the The Rolf Institute
of Structural Integration.