Intake Form

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Intake Form

Please fill out prior to initial consultation &/or first Rolfing or Craniosacral session

Name *

Email/Phone # *

Date of Birth

Primary Medical Caregiver (MD/ND)

Emergency Contact Name/Number/Relationship:

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?

Body History

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

Clear selection

Have you ever given birth?

Yes

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If so, how many times?

Clear selection

Was it a vaginal or cesarean birth(s)?

Vaginal

Cesarean

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Are you currently pursuing, or have you ever pursued, any type of mental health treatment (including psychiatric medication, traditional or non-traditional therapy)? 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; month/year, physical ailment, action taken, result

What pharmaceutical medications, over-the 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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