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

Full name

Email address

Street Address

City

Postal Code

Telephone

Mobile

Height (cm)

Weight (kg)

How do you perceive your Gender?

Date of Birth (dd mm yyyy)

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

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Goals

What are your goals? What do you hope to gain from this treatment?

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What do you consider to be your health strengths?

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What do you consider to be your health challenges?

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Occupation

What is your Profession?

How many years do you work in your profession?

What aspects do you find pleasing or satisfying in your work?

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What aspects do you find stressful or unsatisfying?

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Do you have an online resource where I can see you in Movement? (speaking, performing, dancing, lecturing) or have any representation online (website, video, social media) of what you do?Website, blog, video where I can see Movement, Anything you find relevant

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Stress

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

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Sleep Patterns and Starting the day

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

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

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What time do you usually go to bed?

Is your bedtime fairly consistent or rather variable?

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What time do you usually get up?

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Do you usually get up around the same time, or is wake up time quite variable?

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How often do you take naps during the day?

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Do you snore?

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How do you typicaly start your day?Do you have daily morning rituals?

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Exercise and Diet

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

YesNo

If yes, what is your practice?

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If you have a Movement based personal practice, what would you consider as Movement? What does it mean for you?

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What is your “edge” in your practice? What limits, disrupts, sabotages, or deeply inspires your practice?

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

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What is food for you?

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Listening and Sound

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

YesNo

What aspects do you 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 you feel at home?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 you:If yes, please explain

Heart ConditionRespiratory ProblemsHigh / Low 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 you have any chronic or acute discomfort?If yes, please elaborate

YesNo

Please describe

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

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Are you 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 you have been involved. Did you have fractures?

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Did you 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 you 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 you have any scars on your body?If yes, please explain

YesNo

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

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What special features do your scars have?Please describe their color and texture

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Have you had previous Scar treatment in the past? Please explain

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If you had previous Scar treatment, to your view how succesful was it? Please explain

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

YesNo

Please describe

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Relationship and Personal status

Do you share your life with another?If yes, what is the relationship?

Do you parent children?If yes, how old?

For Women

Are you currently pregnant?If so, please explain

YesNo

Which week? what is your due date?

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Were you pregnant in the past?If so, please explain

YesNo

Please describe your history of pregnancies and/or child births. For each event, please give at least approximate dates, as well as the course of the event and outcome.

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Are you planning on becoming pregnant?

YesNo

Do you have an IUD/Coil?

YesNo

Bodywork History

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

YesNo

If so, with whom and when?

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Please describe your past Rolfing experience:

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Please describe your previous Bodywork / Massage experience, including frequency of visits, when and how many sessions

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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

Please 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 am interested

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