Health History Form - 5th Line Rolfing

Please fill out this form as completely as possible. The more information I have about your current health and background, the more successful we can be during your treatment.

Name

First

Last

Phone

Date of birth

Occupation

Emergency contact

First

Last

Emergency contact phone number

Have you received Rolfing® or Structural Integration before?

Are you currently under the care of a doctor/chiropractor/holistic practitioner?

Please describe the current condition that you're seeking treatment for and how are you hoping to benefit and improve from the Rolfing® Ten Series or individual session?

What treatments have you received for the primary condition you're here to address?

Are you currently taking any topical OR internal medications (OTC or prescription)?

Please list any surgeries or major health conditions and approximate dates

Please list any known injuries or traumas (car accidents, falls, sprains/strains, broken bones, emotional or sexual abuse):

What is your current exercise program?

Primary area of pain

Level of pain

Secondary area of pain

Level of pain

Third area of pain

Level of pain

Is there anything else you would like me to know or how I can best support you in this process?

CANCELLATION POLICY

I always want to give you the best possible service. To help me accommodate my clients and maintain a smooth schedule, I have established the following cancellation policy. Please check each box to acknowledge that you've read and accepted the policy.

You may cancel or reschedule your appointment but you must give me more than 24 hours notice.

I Agree

If you cancel or reschedule your appointment with less than 24 hours notice, a cancellation fee of $75.00 applies.

I Agree

If you do not show up for your appointment and do not give notice, you will be charged a $75.00 no-show fee.

I Agree

Please enter your initial to confirm that the information you've given above is accurate and correct to the best of your knowledge.