Medical Questionnaire

Your Name (required)

Your Email (required)

Phone

Address

City

State

Zip

Primary Care Doctor

Referred By

Doctor's Telephone

How did you hear about Rolfing?

How did you find Sam Adams?

What are your reasons for receiving Rolfing?

Do you have any physical complaints?

When and How did they develop?

How was the complaint treated?

Are you satisfied with the results?

Do you grind your teeth?
 Yes No

Do you sleep well?
 Yes No

Do you smoke?
 Yes No

Have you had surgery in the past few years?
 Yes No

Are you pregnant?
 Yes No

If so, what is your due date?

Please list current medications, if any, and their purpose

What physical routines do you follow per week?
 Weights Yoga Gym Gyrotonics Pilates

Please check and and all of the following that have applied to you
 Arthritis Broken bones Neck pain Varicose Veins Heart Condition Low Blood Pressure High Blood Pressure Shortness of Breath Severe menstrual pain Dizziness Headaches Burstitis Skin Disorders Back Pain Chest Pains P.M.S. Herniated Disc Extremity Numbness Cancer Diabetes Edema Diarrhea Sinusitis Sciatica Abdominal hernia Ringing Ears Fainting Spells Loss of Balance Blood Clots Constipation

All information is confidential, unless an authorization for the release of information is requested by the client.
Electronic Signature (please type your name, required)

Sam Adams provides Rolfing in Baltimore and New York
Sam Adams provides Advanced Rolfing, massage therapy, Functional Movement Screening, and Selective Functional Assessment.
Sam Adams, massage therapy, rolfing, and functional movement screening expert.
Sam Adams offers you a uniquely effective synthesis of Rolfing, massage therapy, physical therapy (including FMS and SFMA) medical massage, and Rolf Movement therapy.