Rolfing® Minnesota, Inc.

Kristin Harlander, M.S., Certified Advanced RolferTM, Rolf Movement® Practitioner

HEALTH QUESTIONAIRE

PLEASE PRINT CLEARLY. This is used as a guideline and will be further discussed with your RolferTM.

Name: Date:

Address: Weight:

Height:

Phones: Birth date:

Email: Occupation: ______

1. How did you learn about rolfing?

2. Do you have or have you ever had any of the following conditions, illnesses, problems?

Circle yes (Y) or no (N). Be descriptive when appropriate.

Heart Condition Y N Respiratory Problems Y N

High/low Blood Pressure Y N Eliminatory Problems Y N

Hemophilia Y N Circulatory Problems Y N

Diabetes Y N Digestive Problems Y N

Cancer Y N Contact Lenses Y N

Convulsions Y N Dentures/Removable Bridges Y N

Thyroid Problems Y N Orthodonture (Braces) Y N

Osteoporosis Y N Phlebitis Y N

Arthritis Y N Other

3. Are you currently under the care of a medical physician, chiropractor, therapist? Y N

If YES, for what?

If NO, date of last physical

List medication taken in the past 6 months:

4. Please describe any past injuries, accidents and surgeries:

Date occurred / What happened, area(s) affected / Treatments

5. What is your current exercise program and diet?

6. What is your previous bodywork/massage experience, including how frequent:

7. What would you like to gain from your rolfing experience?

8. Please mark on the diagram below where you are having discomfort and how that area feels (i.e., sharp pain, dull ache, tightness, etc.)

APPLICATION AND CONSENT: Rolfing® Structural Integration

I hereby apply for a standard series of processing in Rolfing Structural Integration.

I fully understand the purpose of Rolfing® is to balance and align the physical body so that it is supported and maintained by gravity in three-dimensional space. This is done through direct manipulation and education so that greater economy and freedom of body movement are achieved.

I understand Rolfing is not involved with the treatment of disease of any kind, nor does it substitute for medical diagnoses or treatment when such attention is needed.

The RolferTM does not treat, prescribe or diagnose an illness, disease, or any other physical or mental disorder of the person. Nothing said or done by a Rolfer should be misconstrued to be such.

I understand it is necessary for the Rolfer to touch my body in order to assist me in establishing balance and alignment in the body.

I give Kristin Harlander, Certified Advanced Rolfer, my permission and consent to do all those things necessary in helping me establish balance and alignment, including, but not limited to touching my body. I give the Rolfer full privilege and license to work on my body in such a way to restore and establish balance and alignment therein.

Furthermore, I understand that any relief of physical or emotional symptoms is coincidental in the organization of the total human being and is not the basic goal of Rolfing.

All records maintained by the Rolfer regarding the client below are confidential and will require prior written approval from the client to be released to anyone other than the client.

Date:______Client Signature:______

CANCELLATION POLICY

I agree to pay a $45.00 cancellation fee for appointments cancelled without 24 hours notice. Acts of nature and God are exempt. For example; snow storm and illness (yours or your child).

Date:______Client Signature:______

2722 Hwy 694, Suite 105, New Brighton, MN 55112 phone: 612.799.5879 email: