Intake Form - Rolfing Tai Chi London

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General Data Protection Regulations

Rolfing® Tai Chi London will keep and use the information below and any subsequent notes taken during treatment :

To monitor progress during your treatment
To contact you to arrange appointments or with information relevant to your ongoing Rolfing® treatment or Tai Chi instruction.

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Please note: I cannot see you without first having received your info form and agreement to terms.

Intake Form:

Name:

Email:

Telephone:

Address:

Date of Birth:

Occupation:

Your Health: Please Include anything you a currently receiving treatment for or details of any medication you are taking:

Health Details:

Please tell me about the things you would especially like to work on. What are your goals for these sessions?

Goal Details:

Please use this box for anything else you would like me to know.

More Details:

Have you had rolfing ® before?

For women only: Are you pregnant? Please let me know at any stage if this changes.

Pregnant: Yes/No:

Do you have an IUD (Coil)? Yes/No:

Do you have any pins, plates or electronic divices: Yes/No:

Have you ever received steroid or cortisone injections? Yes/No:

If yes how many and where?

Do you wear orthotics?

Do you feel that you are available and ready for change?

Preferred Location:

I have read and agree to the Terms and Conditions

Type I Agree:

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Intake Form.