Rolfing® Structural Integration Health Intake Form

This form is used as a guideline for further discussion about your general health and well-being.

Name *

First

Last

Email *

Phone Number

Age

Weight

Height

Do you have or ever had any of the following conditions, illnesses, or problems?

Heart condition
Respiratory problems
Circulatory problems
Digestive problems
High blood pressure
Low blood pressure
Hemophilia
Convulsions
Diabetes
Cancer
Other

Please describe any of the above, including approximate dates of illness and treatment:

Are you currently under the care of a medical physician, chiropractor, or other therapist? If yes, please describe:

Approximate date of last physical:

What medication(s) and supplement(s) have you taken during the last six months?

Any past injuries? (Please describe approximate dates, sites of injuries and treatments):

Any past accidents? (Please describe approximate dates, sites of injuries and treatments):

Any past surgeries? (Please describe approximate dates, sites of injuries and treatments):

Any previous bodywork? (Please describe approximate dates, sites of injuries and treatments):

What would you like to gain from Rolfing Structural Integration?

Where did you learn about Rolfing SI?

Questions prior to beginning?

Cancellation / No-Show Policy *

I understand

Structure and Dynamics requires all clients to provide at least 24 hours notice (or 48 hours notice for Monday appointments) when canceling or rebooking an appointment. Late cancellations or no-shows will be charged for the full session using the payment method provided at booking. Structure and Dynamics also abides by this policy - in the event the company exercises a late cancellation or no-show, the client will be compensated for a session of equal time.

Phone

Please feel free to ask questions at any time during the process. Client communication is vital to the work.