New Client Intake Form printable pdf download

Upright Rolfing 

New Client Intake Form 

Name (Print)___________________________

Phone (

)________________

Date of Birth_______________

Address___________________________________City________________________State___________Zip__________

Email _______________________________________

Occupation_____________________________________

What brings you to Rolfing and what do you hope to experience from the work?__________________________________

_________________________________________________________________________________________________

How did you hear about me? (ie- yelp/Rolf Institute website/google search/walk by/referral) _______________________

Have you been Rolfed? Yes __ No __ How many sessions? _______ Are you under the care of a physician? _________

For what condition(s)? ______________________________________Does he/she approve of your being Rolfed? _____

Are you on any medication prescribed by a physician? Yes ___ No ___ What__________________________________

Do you use aspirin or other non-prescription drugs? Yes ___ No ___ What type and how often?____________________

Are you currently involved with any type of physical or mental therapy? (acupuncture, psychotherapy, massage, etc)

_________________________________________________________________________________________________

Do you exercise? Yes ___ No __ What kind of exercise and how often?_______________________________________

What is your diet generally like? _______________________________________________________________________

How do you like to relax? __________________________________ Do you feel tired very often? ___________________

How is your sleep at night? ________________ What are stressors in your life right now? ________________________

How does your livelihood or your habits/hobbies affect your body? ____________________________________________

_________________________________________________________________________________________________

Do you have any chronic complaints? (things you have accepted as a constant, ie headaches, constipation, anxiety)?

_________________________________________________________________________________________________

Please list any operations, accidents, injuries or serious illness that you have had ________________________________

_________________________________________________________________________________________________

New Client Intake Form