Intake Form

Casey Gates Rolfing
5105 SE Hawthorne Blvd
Portland, Or 97214
www.caseygatesrolfing.com
caseygatesrolfing@gmail.com
(971) 413-3106

PERSONAL INFO
Name *
Name
Phone # *
Phone #
Date of Birth
Date of Birth
Address
Address
Emergency Contact Name
Emergency Contact Name
Emergency Contact Phone #
Emergency Contact Phone #
MEDICAL INFO
Are you currently taking any medication?
Are you currently pregnant?
Do you suffer from chronic pain?
Have you had any musculoskeletal injuries?
I eat healthy
I live an active lifestyle
I get enough sleep at night and feel rested in the morning
Please check all that apply
BODYWORK INFO
What pressure do you prefer?