Rolfing® Iowa

Intake Form

Please take a moment to fill out this pre-session intake form. This will help speed up the intake process when you arrive for your appointment.

* denotes a required field.
Personal Info:
First Name:  
Last Name:  
Height:  
Weight:  
Date of Birth:  
In mm/dd/yyyy format
Address:  
City:  
State:  
Zip:  
Email: *
Phone:  
555-555-5555  
Health Info:
Reason for visit:  
How did condition develop:  
What makes the condition worse:  
What makes condition better:  
Within the past year, have you been under the care of a health provider(s):  
i.e., chiropractor, physician, psychotherapist, alternative practitioner, etc.  
If yes, please list name of provider and condition:  
Health History:
Please check any condition that applies to you:  
 
What medical conditions pertain to you that do not appear on the list:  
Are you currently taking any over the counter medications:  
If yes, please list the name of the medication and reason for using:  
On a daily basis, what is your average consumption of
Coffee:  
Alcohol:  
Cigarettes:  
Have you received Structural Integration before:  
Describe any significant bodily injuries that you can remember and when they happened:  
i.e., accidents, sprains, falls, bone fractures, physical abuse, etc.  
Referred by:  
Policies
Agreement Terms
Because a massage therapist must be aware of any existing physical conditions that I have, I have listed all my known medical conditions and physical limitations, and I will inform my massage therapist of any changes in my physical health. I understand and agree that (1) the massage therapy that I am given is for the purpose of stress reduction, relief from muscular tension or spasm, and for improving circulation; (2) that a massage therapist neither diagnoses illness, disease, or any other medical, physical or mental disorder, nor performs any spinal manipulations; (3) I am responsible for consulting a qualified physician for any physical ailments requiring diagnoses. I agree that all the services rendered to me are charged directly to me and I am responsible for payment unless prior arrangements have been made. I agree to pay for all scheduled appointments that I am unable to keep unless I notify my therapist at least 48 hours in advance.
Acceptable Payment Methods
Visa, MasterCard, Cash, Check
Cancellation Policy
No charge will be incurred for cancellation notification given at least 48 hours from the time of the scheduled session. Likewise, no charge will be incurred for cancellation given in less than 24 hours lead time when the appointment is subsequently re-booked with another client. If the appointment time is not resheduled with another client for the same time you were originally scheduled you will be responsible for payment in full. All parties are responsible for handling career and other life demands that compete with the time of the scheduled session appointment. By submitting this form, you indicate that you have read these policies.
© 2018 Rolfing® Iowa. All Rights Reserved.