Nir Tiomkin Rolfing® & Movement

New Client Intake Form


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





Sleep Patterns and Starting the day

Exercise and Diet

Do you have a Physical, Movement or Meditation practice?If yes, please explain

Listening and Sound

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

Health History

Please check any of the following boxes that apply to you:If yes, please explain
Do you have any chronic or acute discomfort?If yes, please elaborate
Are you presently under the care of a medical physician / chiropractor / therapist / counsellor?If yes, please explain
Did you have any surgery?If yes, please explain
Are you aware of any continuing effects from the surgeryIf yes, please explain
Have you had any imaging (Xrays, CT scan, MRI, Diagnostic Ultrasound ect') in the past 5 years?If yes, please explain why
What Imaging have you had in the past 5 years?If "Other" please explain


Do you have any scars on your body?If yes, please explain
Have you received any injections (steroidal, botox, Novocain, epidural, etc) in the past 6 months?If yes, please explain

Relationship and Personal status

For Women

Are you currently pregnant?If so, please explain
Were you pregnant in the past?If so, please explain
Are you planning on becoming pregnant?
Do you have an IUD/Coil?

Bodywork History

Have you ever received Rolfing sessions?If so, with whom and when?

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.

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

NOTE: To print a copy of your intake form, do so prior to clicking on the Submit Form button with your internet browser.

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