Intake Form ~ RothSI Structural Integration

Intake Form

Please complete this form before your first appointment either online or download and bring with you. I look forward to working together.

Name*

Date
MM slash DD slash YYYY

Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Please answer the following questions:
Are you currently taking any medications?
If yes please explain:
Have you had any recent surgical procedure or injury?
If yes please explain:
Are you currently seeing a Chiropractor, Physical Therapist, or Physician for an ongoing issue?
If yes please explain:
What is your level of stress?

Low

1

2

3

4

5

High
Are you allergic to any lotions or oils?
Please list them:
Select any conditions that apply to you, past and present.Please add yours comments to clarify the condition.

Please select any of the following conditions that apply to you, past and present. Please add yours comments to clarify the condition below.
Musculo-Skeletal
Circulatory/Respiratory
Digestive
Nervous System
Reproductive System
Other
Additional Comments:
I understand that a Structural Integrator does not diagnose disease, illness, or prescribe any treatment or drugs, nor do they provide spinal manipulation. I understand Structural Integration is a manual connective tissue therapy and the therapist will work on muscles and fascia in a specific way to relieve tension and increase wellness. I understand that Structural Integration is not a substitute for medical treatment or medications. I have stated all of the conditions that I am aware of, and this information is true and accurate. I will inform the health care provider of any changes in my status. I understand that a 24-hour cancellation is required for scheduled appointments.
Consent
Client’s Signature
Date
MM slash DD slash YYYY

Name
This field is for validation purposes and should be left unchanged.

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