Health History Form 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. Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Phone number *Date of birth *OccupationEmergency contact *FirstLastEmergency contact phone number *Have you received Rolfing® or Structural Integration before?YesNoAre you currently under the care of a doctor/chiropractor/holistic practitioner?YesNoPlease 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)?YesNoPlease list any surgeries or major health conditions and approximate datesPlease 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 painLevel of painOneTwoThreeFourFiveSixSevenEightNineTenSecondary area of painLevel of painOneTwoThreeFourFiveSixSevenEightNineTenThird area of painLevel of painOneTwoThreeFourFiveSixSevenEightNineTenIs there anything else you would like me to know or how I can best support you in this process?By entering your initials here, you agree to the above payment and cancellation policy *Submit