new client intake form Please complete the following form BEFORE booking your appointment. Name * First Name Last Name Preferred Pronouns * Email * Phone * (###) ### #### Birthdate * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact Name * First Name Last Name Emergency Contact Phone * (###) ### #### Primary Physician * First Name Last Name Have you ever received Rolf ® Structural Integration? If yes how many sessions? * Do you take prescriptions? If yes please list them. * Are you pregnant? If yes how many weeks? Any high risk factors? * Do you currently have an IUD? * Do you currently have a birth control implant? * Please describe any surgeries you've had. * Have you had any spinal infections, tumors, injuries, bone changes or conditions? If yes please share details including your timeline, what kind of injury and where in your body? * Are you currently experiencing any infection or disorder? Head cold, bladder infection, skin irritation, varicose veins, other: * Have you ever been diagnosed with Cancer? If yes please share your timeline, what type of cancer, and where in your body? * Please describe any orthopedic current or past injuries/ problem areas not already described. If none, state N/A. * Has anything eased your discomfort or supported mobility? If yes please describe procedures, exercises, or self-care practices. * Please describe any type of medical care you are currently receiving: * If your job requires physical activity, please describe. * Do you have regular health practices? If yes what are they? Mindfulness, exercise, diet, supplements, pace of life, nervous system practices, joyful hobbies, other healing modalities * On average, how many times per week are you physically active? * Rarely 0-1x per week Somewhat regularly 2-3x per week Often 4x per week If you are physically active, what activities do you enjoy? Please list all. * What is your main goal for this session? * What inspires you? * What are your aspirations for the coming year. * How did you hear about this work or my practice? * Please check if you have a history of any of the following: * Select all that apply Blood Clots (Legs or Lungs) Deep Vein Thrombosis Phlebitis/Varicose Veins Cancer Low Back Pain AIDS/HIV Hepatitis Lymes Sensory Loss/Change Ringing In Ears Pinched Nerve Sciatic Pain Multiple Sclerosis Arthritis Fibromyalgia Herniated/Bulging/Ruptured Disks Unstable/Weak Muscles Muscle Spasms Seizures/Convulsive Disorders Dizziness/Vertigo Headaches/Migraines Jaw Pain/TMJ Difficulty Sleeping Mentally Restless Anxiety/Depression Suicidal Tendencies Easily Angered Constipation/Loose Stools Disordered Eating Digestive Problems Low Energy Osteoporosis Connective Tissue or Collagen Diseases Warts, Rashes Other Skin Infections or Virus-Herpes//Shingles Allergies (Nuts, Food, Latex, Seasonal) Asthma Kidney or Lung Disorders Shortness of Breath Diabetes Tuberculosis Physical or Emotional Trauma High Blood Pressure Low Blood Pressure Stroke Pacemaker Heart attack Chronic Congestive Heart Failure Reproductive System Challenges Uterine Fibroids/Cysts Endometriosis Pins/Plates/Wires/Artificial Joint By signing below, you agree to the following. I have completed this form to the best of my ability and knowledge and agree to inform my CMT and Rolf ® Structural Integration Practitioner if any of the above information changes at any time. * Signature and Date I, (Your First, Middle, and Last Names) * hereby acknowledge and consent to the following: I understand the purpose of Rolf ® Structural Integration is to align and lengthen the body on it's center line and in space. Alignment occurs through a series of physical contacts, functional movement education and somatic awareness. Rolf ® Structural Integration is a modality of manual therapy focusing on the fascia. Fascia is the connective tissue that surrounds muscle and bone. I understand it is necessary for my practitioner, operating through Integrate With Michelle, to touch my body in an appropriate manner in order to assist me in my Rolf ® Structural Integration experience. I give my permission and consent to practitioners operating through Integrate With Michelle to physically assist my body in the Rolf ® Structural Integration session. I further understand that I may at any time, revoke such permission and consent, and can choose to discontinue the session and any further Rolf ® Structural Integration appointments. I understand that revocation of my involvement in Structural Integration does not release me from the cancellation policy. Signature and Date * Thank you!
