Client Intake Form

Name *

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Last

Email *

Date of Birth *

Gender *

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Today's Date *

How you Hear About Me *

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Primary Medical Caregiver (MD/ND): *

Address *

Emergency Contact: *

Intent for Sessions: *

What is your primary reason for coming to Rolfing? *

What, if any, other forms of medical treatment or complementary care have you pursued for this primary reason? *

What do you most value about your body and its structure at present? *

What is your livelihood (lawyer, stay at home parent, car mechanic, etc.)? What does it require of your body (lifting, commuting, typing, sitting, etc.)? What physical impact do your hobbies (carpentry, knitting, cooking, etc.) have? *

What is your relationship to movement or formal exercise? Do you practice any form of movement (walking, manual labor, qi gong, dancing, cycling, swimming, etc.) with regularity? If so, what form(s) and with what typical frequency? *

What is your customary sleeping position? *

Are you, or could you be, pregnant? YES or NO Have you ever given birth? YES or NO *

If so, how many times? __ Was it a vaginal or cesarean birth(s)? *

Do you have any history of STDs? YES or NO If yes, which? *

Are you currently pursuing, or have you ever pursued, any type of mental health treatment (including psychiatric medication, traditional or nontraditional therapy)? YES or NO If yes, which? *

Are there any related mental or emotional issues of which I should be aware? *

List all accidents, injuries, surgeries, and orthodontics to date and related care history (continue on back, as necessary). Month/Year Physical Ailment Action Taken Result *

What pharmaceutical medications, overthe counter drugs, and dietary supplements/vitamins do you take? Drug/Supplement Name Your Purpose for Usage Frequency of Intake *

Are there any other health conditions or history of which I should be aware? If yes, please explain. *

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