Nir Tiomkin Rolfing® & Movement

New Client Intake Form, Kids and Minors

Rolfing® Structural Integration |

Rolf Movement Education™ |

Ashtanga Yoga |

BreathWork |

ScarWork |

Please note:
Please take the time to fill in the form, do not rush through. It is designed to help us get around the themes that are most important for you and relevant for your sessions.

Fill in the form in one sitting. Leaving the form partly finished to return at a later point, navigating out and back, or refreshing the browser while filling in the form – may risk losing all your filled-in information!

Appreciating you for taking the time,

I look forward to working with you!

Nir Tiomkin

Full nameMinor first and Family name

Guardians/Parent namefirst and family name

Email address

Postal Street AddressStreet and number

City

Postal Code

Telephone

Mobile

Child's Height (cm)

Child's Weight (kg)

Only if applicable: how does your child perceives themselves among the following?Check what you most identify with

Child's Date of Birthddmmyyyy

Please describeWhen considering Gender orientation, what sits with them the most?

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Intentions

What would you most like to get out of our session together?

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What do you consider to be your child's health strengthes?

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What do you consider to be your child's health challenges?

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Occupation

Which grade is your child?

Which institute do they attend?

What aspects do they find pleasing or satisfying in their everyday life?

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What aspects do they find stressful or unsatisfying?

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Stress

How stressful do you feel your child is currently?Please describe the stressors in their life.

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Sleep Patterns and Starting the day

How well do you feel they sleep? Describe in detail:

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How well rested do they usually feel when they wake up in the morning?

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What time do they usually go to bed?Is bedtime fairly consistent or rather variable?

What time do they usually get up?Do they usually get up around the same time, or is wake up time quite variable?

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Do they snore?

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Exercise and Diet

Does your child have a Physical, Movement , or other practice?If yes, please explain

YesNo

If yes, what is the practice?

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What is their current diet?What are their food choices?

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Listening and Sound

Do they appreciate listening to Music or certain Sounds?If yes, please explain

YesNo

What aspects do you beleive they appreciate about it, that made you choose Yes?Please explain

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Is there a particular Music or sounds that by hearing makes them feel whole?What kind of Music resonates with you te most?

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Health History

Please check any of the following boxes that apply to your child:If yes, please explain

Heart ConditionRespiratory ProblemsHigh Blood PressureLow Blood PressureEliminatory ProblemsHemophiliaCirculatory ProblemsDiabetesDigestive ProblemsCancerContact LensesConvulsions/ Seizures/ EpilepsyDentures / Removable BridgeThyroid ProblemsDeviated septum (nasal)Osteoporosis (bone mass)Headaches / MigrainesArthritisKnocked unconsciousOsteomyelitis (bone disease)Phlebitis (vein Inflammation)SmokingDrinking Alcohol

Please describe

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Do they have any chronic or acute discomfort?If yes, please elaborate

YesNo

Please describe

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Please list any medications that they have taken in the last 6 monthsPlease describe for what are they prescribed

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Are they presently under the care of a medical physician / chiropractor / therapist / counsellor?If yes, please explain

YesNo

Please describe

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Describe all significant injuries including: Cuts, Burns, Broken bones, Whiplash, Concussions & other Impact injuries, Hard Falls, Crush Injuries, Piercing Injurie

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Describe motor vehicle accidents they have been involved. Did they have fractures?

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Did they have any surgery?If yes, please explain

YesNo

Please explain what the surgery was about:

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Please describe how successful do you feel the surgery was?

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Are you aware of any continuing effects from the surgeryIf yes, please explain

YesNo

Please describe the effects from your surgery

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Have they had any imaging (Xrays, CT scan, MRI, Diagnostic Ultrasound ect') in the past 5 years?If yes, please explain why

YesNo

Please describe

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What Imaging have you had in the past 5 years?If "Other" please explain

XraysCT scansMRIDiagnostic UltrasoundOther

Please describe what other imaging you have done

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Scars

Do they have any scars on their body?If yes, please explain

YesNo

Please describe the incident as far as you remember. Where and how old are the scars?

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If they have scars, do you feel they limit their movement?Please describe their color and texture

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Have your child recently received any injections (steroidal, botox, Novocain, etc) in the past 6 months?If yes, please explain

YesNo

Please describe

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Family

Does your child have siblings?If yes, where are they located among them?

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Please share how was their pregnancy, how was their birth?

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Who was their caregiver after their birth?

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Bodywork History

Have your child ever received Rolfing sessions?

YesNo

If so, with whom and when?

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Please describe their past Rolfing experience and relate to the following: In todays perspective, what did it evoke in their life, what was the added value?

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If applicable, please describe their previous Bodywork / Massage experience, including frequency of visits, when and how many sessionsWhat was most effective?

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Has anyone else in the Household experienced Rolfing sessions?If yes, how was the work for them?

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How did you learn about this practice?

Please assist by taking a moment to complete this questionnaire.
Your input is vital in improving our communications.

Online Internet Search EngineGoogle MapsPrinted Advertisement (flyers, Postcards)Online directoriesEuropean Rolfing AssociationRolfing Verband DeutschlandYoga registryReferralOther

If you remember, please list the terms used in your search(Such as: Rolfing, Yoga, Nir Tiomkin, Ashtanga, ScarWork etc.)

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Please describe Online directory or registry

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Where did you pick up a printed material?

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Would you mind sharing who reffered you?

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Other - Please describe

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Have you appreciated reading previous clients reviews about Nir Tiomkin | Rolfing® Praxis & Movement, on the website or Online?Please choose

YesNo

If yes, while reading - what aspect was resonating with you the most?

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Website Feedback

How useful was the website www.nirtiomkin.com to you?

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What did you like about it?

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Any suggestions for improving?

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Newsletter registration

Check in the box to support your sessions with follow ups and inspirational advice as you go through this eye-opening evolving journey.

Yes, I'd like to

Consent to Data Processing (Privacy)

I expressly consent to the processing of my health-related information provided in this form for the purpose of my Rolfing sessions, bodywork services and scheduling. I have read and understood the Privacy Policy. I have been informed that I can revoke this consent at any time.

Yes,I consent

Nir Tiomkin Rolfing® & Movement

New Client Intake Form, Kids and Minors

Rolfing® Structural Integration |

Rolf Movement Education™ |

Ashtanga Yoga |

BreathWork |

ScarWork |

Occupation

Stress

Sleep Patterns and Starting the day

Exercise and Diet

Listening and Sound

Health History

Scars

Family﻿﻿

Bodywork History

How did you learn about this practice?

Website Feedback

Newsletter registration

Family