Personal History Form

PERSONAL HISTORY FORM AND HEALTH QUESTIONNAIRE

Name *

Address

Apt, suite, etc.

Country

City

Zip code

Landline

Phone *

Date of Birth *

Height

Weight

Have you ever received Rolfing sessions (whom and when)?

What other bodywork treatment have you had (what and when)?

Do you have any acute or chronic pains?

Have you had any fractures or operations?

Have you had, or are you having, psychotherapy or psychiatric treatment?

What illnesses have you had in the last 12 months?

What medication have you taken in the last 6 months?

Do you wear any of the following?

Contact Lenses

Hearing Aid

Dentures

Bridge

Tick all that apply.

What goals are you hoping to achieve with Rolfing?

For women (because of abdominal work):-

Do you wear a coil?

Yes

Are you pregnant (months)?

Please take the number of months.

Privacy Notice

So that I can provide you with a safe and beneficial Rolfing session and contact you when required, the details you have provided to me will be most helpful to me. It is important that I
gain your consent to me holding this information for you, which I will keep secure and
private. I will not share your information with anyone else.

Please sign at the end of this form to confirm your consent.

I have completed the details I wish to give and consent to you holding and using it, in respect to my attending Rolfing sessions where you are the therapist.

Signature *

Reset Signature

Signature is required.

Name

Date *

Required Forms

For women (because of abdominal work):-